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A   MANUAL 


OF   THE 


INJURIES  AND  SURGICAL  DISEASES 


FACE,  MOUTH,  AND  JAWS. 


BY 

JOHN  SAYRE  MARSHALL,  M.D.(sv»a.un,v.), 

Former  Professor  of  Dental  Pathology  and  Oral  Surgery,  and  Emeritus  Professor  of  Oral  Surgery 

of  the  Dental  Department  of  Northwestern  University.    Former  Professor  of  Oral  Surgery 

of  the  American  College  of  Dental  Surgery.    Attending  Oral  Surgeon  to  St.  Luke's 

Hospital,  Mercy  Hospital,  and  Baptist  Hospital  of  Chicago.    Fellow  of  the 

American  Academy  of  Dental  Science.      Member  of  the  American 

Dental  Association,  and  of  the  State  Dental  Society  of  Illinois. 

Member  of  the  American  Medical  Association,  and  of 

the  Cook  County  Medical  Society.    President 

of  the   Examining  Board    for  Dental 

Surgeons,  United  States  Army. 


SECOND  EDITION,  REVISED  AND  ENLARGED. 


PHILADELPHIA: 

THE  S.  S.  WHITE  DENTAL  MFG.  COMPANY. 

1902. 


-Copyright,  1897,  by  John  Sayre  Marshall. 
•Copyright,  1902,  by  John  Sayre  Marshall. 


TO 

MY  FRIENDS  AND  CONFRERES, 

JONATHAN  TAFT,  M.D.,  D.D.S., 

AND 

S.  B.  PALMER,  M.D.S., 

IN    REMEMBRANCE    OF   THE    KINDLY    SYMPATHY   AND   ENCOtJRAGE- 

MENT    SO    OFTEN    EXTENDED    IN  THE  EARLIER  YEARS  OF  MY 

PROFESSIONAL  LIFE,   THIS    BOOK    IS    AFFECTIONATELY 

DEDICATED   BY 

THE  AUTHOR. 


PREFACE  TO  THE  SECOND  EDITION. 


The  kindly  spirit  in  which  the  first  edition  of  this  work  was 
received  by  the  profession  and  its  quite  general  adoption  by  the 
American  Dental  Colleges  as  a  text-book  upon  the  subjects  of  which 
it  treats,  has  inspired  the  author  to  present  this  second  edition,  with 
the  hope  that  it  will  receive  the  same  generous  treatment  at  the  hands 
of  the  critics,  and  that  it  will  maintain  its  position  as  a  recognized 
text-book  and  a  reliable  book  of  reference. 

The  work  has  been  thoroughly  revised  and  brought  up  to  date, 
and  much  new  material  has  been  added  to  the  text,  also  many  valu- 
able and  interesting  illustrations  introduced.  On  account  of  the  in- 
crease in  the  subject  matter,  the  review  questions  have  been  omitted 
from  this  edition. 

John  Sayre  Marshall. 

August,  igo2. 


PREFACE  TO  THE  FIRST  EDITION. 


The  plan  of  this  volume  is  the  outgrowth  of  several  years'  ex- 
perience as  a  teacher  of  Oral  Surgery,  in  Medical  and  Dental  Colleges. 
During  these  years  the  author  has  been  more  and  more  impressed  with 
the  disadvantages  under  which  teachers  and  students  have  labored  in 
the  old  system  of  teaching  by  didactic  lectures.  The  same  feeling  has 
been  growing,  year  by  year,  among  many  of  the  teachers  in  the  Ameri- 
can Medical  and  Dental  Colleges,  and  many  of  them  have  expressed 
themselves  as  anxious  to  adopt  a  recitation  system  of  teaching  in  their 
special  departments.  The  greatest  objection  which  has  been  raised  to 
the  inauguration  of  such  a  system  of  teaching  has  been  the  lack  of  text- 
books arranged  upon  a  suitable  plan  for  teaching  by  this  method. 

The  author  has  endeavored  to  fill  this  requirement  in  the  depart- 
ment of  Oral  Surgery  by  the  preparation  of  this  volume.  In  the  selec- 
tion and  presentation  of  the  various  subjects  comprising  the  work,  he 
has  constantly  kept  in  mind  the  particular  needs  of  the  medical  and 
dental  student.  In  Part  First  will  be  found  those  subjects  which  be- 
long to  the  General  Principles  of  Surgery,  while  Part  Second  is  devoted 
to  the  more  common  Injuries  and  Surgical  Diseases  which  are  asso- 
ciated with  the  Face,  the  Mouth,  and  the  Jaws. 

These  subjects  have  been  divided  into  short  chapters,  suitable  to 
class  recitation  work,  and  each  chapter  is  followed  by  a  series  of  review 
questions  covering  the  most  important  facts  presented  upon  each  topic. 
These  questions  can  be  used  by  the  teacher  as  a  basis  for  class  quizzes; 
they  will  also  enable  the  student  to  quiz  himself  upon  every  subject 
presented. 

How  well  the  author  has  succeeded  in  the  undertaking  he  must 

leave  to  the  criticism  of  his  colleagues;  but  he  trusts  that  the  general 

plan  will  meet  with  the  approval  of  all  interested  in  a  better  system  of 

teaching. 

vii 


VIU  PREFACE. 

The  very  excellent  illustrations  upon  Bacteriologic  and  Pathologic 
subjects  have  been  made  from  photo-micrographs  especially  prepared 
for  this  volume  by  the  author's  friend  and  confrere,  Dr.  Vida  A. 
Latham,  of  the  Bacteriologic  Laboratory  of  the  Woman's  Medical 
Department  of  the  Northwestern  University,  and  he  takes  very  great 
pleasure  in  making  this  acknowledgment.  To  Dr.  William  H. 
Knapp,  of  Chicago,  he  is  also  indebted  for  valuable  services  rendered 
in  photographing  some  of  these  slides  and  for  the  photo-micrographs 
of  the  karyokinetic  figures;  and  to  T.  Charters  White,  of  London, 
England,  for  several  interesting  photo-micrographs. 

Especial  thanks  are  due  to  the  various  authors  quoted  in  the  work, 
for  much  valuable  information  gathered  from  their  labors,  and  also  to 
Dr.  N.  Senn,  Mr.  Christopher  Heath,  Mr.  J.  Bland  Sutton,  Dr.  W.  D. 
Miller,  and  to  their  publishers,  W.  B.  Saunders,  Churchill  &  Co., 
Cassell  Publishing  Company,  The  S.  S.  White  Dental  Manufacturing 
Company,  and  F.  A.  Davis,  for  courtesies  extended  in  permission  to 
use  many  valuable  illustrations. 

John  Sayre  Marshall. 


CONTENTS. 


PART    I. 

CHAPTER   I. 

Surgical  Bacteriology. 

Parasites.  The  Microscopic  Study  of  Bacteria.  Functions  of  Bacteria. 
The  Pyogenic  or  Pus  Microbes.     Infection i 

CHAPTER   II. 

Surgical  Bacteriology  (Continued). 

Action  of  Bacteria.     The  General  Principles  of  Antiseptic  Treatment 21 

CHAPTER  III. 

Inflammation. 

Inflammation.  Irritation.  Hyperemia.  Exudation.  Temperature.  Pulse. 
Symptoms  of  Acute  Local  Inflammation.  Description  of  the  Inflam- 
matory Process  in  the  Vascular  Tissues 3^ 

CHAPTER  IV. 

Inflammation  (Continued). 

Suppuration.  Pus.  Constitutional  Symptoms  of  Acute  Inflammation. 
Sthenic  Fever.  Asthenic  Fever.  Predisposing  Causes.  Symptoms  and 
Diagnosis.      Prognosis 54 

CHAPTER  V. 

Treatment  of  Inflammation. 

Curative     Treatment.      Local      Treatment — Depletion— Rest — Cold — Heat. 

Constitutional    Treatment — Diet 61 

CHAPTER  VL 

Chronic  Inflammation. 

Causes.     Induration.     Hypertrophy.     Tumefaction.      Fatty    Degeneration. 

Caseation.      Treatment— Local — Constitutional 68 

CHAPTER  VIL 

Abscess. 

Definition.  Causes.  Classification.  Acute  Abscesses— Symptoms— Treat- 
ment—Antiseptic  Solutions.     Methods  of  Opening  Abscesses.     Chronic 

Abscess — Causes — Symptoms — Treatment 72 

ix 


X  CONTENTS. 

CHAPTER  VIII. 

Ulceration.  page 

Definition.      Causes — Age — Sex — Occupation — Traumatism.      Classification. 

Healing.      Prognosis.     Treatment — Operative — Constitutional 80 

CHAPTER  IX. 

Necrosis,  Caries,  and  Gangrene. 

Necrosis — Definition — Causes.  Caries — Definition — Causes.  Gangrene — 
Definition — Causes.  Dry  Gangrene  or  Mummification.  Moist  Gan- 
grene.    Symptoms.     Prognosis.     Treatment 90 

CHAPTER  X. 

Traumatic  Inflammatory  Fever. 

Definition.     Causes.     Treatment 102 

CHAPTER  XL 

Septicemia. 

Definition.  Causes.  Avenues  of  Infection.  Sapremia — Symptoms.  Symp- 
toms of  Septicemia — Diagnosis — Prognosis — Treatment 106 

CHAPTER  XII. 

Pyemia. 

Definition.     Predisposing  Causes — Climate — Age  and  Sex.     Active  Causes. 

Symptoms.     Diagnosis.     Prognosis.     Treatment 113 

CHAPTER  XIII. 

Erysipelas. 

Definition.  Causes.  Symptoms.  Diagnosis.  Prognosis.  Varieties.  Ery- 
sipelas of  the  Mucous  Membrane.     Treatment 120 

CHAPTER  XIV. 

Tetanus. 

Definition.  Causes.  Period  of  Incubation.  Forms  of  the  Disease.  Acute 
Tetanus — Symptoms — Diagnosis.  Chronic  Tetanus — Prognosis — Treat- 
ment       130 

CHAPTER  XV. 

Shock  and  Collapse. 

Shock — Definition.  Collapse.  Pathology — Symptoms — Prognosis — Treat- 
ment.    Shock  from  Dental  Operations 138 


CONTENTS.  Xi 

CHAPTER  XVI. 
Ligatures,  Sutures,  and  Suturing. 

PAGE 

Ligatures — Catgut — Kangaroo — Silkworm-gut — Silver  Wire.  Ligation  of 
Vessels.  Sutures — Continuous — Interrupted — Pin — Quilled — Clamp — 
Button — Buried — -Cobbler's — Shotted    148 


PART    II. 

CHAPTER  XVII. 

Wounds. 

Definition.  Classification.  Healing  of.  Methods  of  Healing — First  Inten- 
tion— Second  Intention — Third  Intention.     Surgical  Cleanliness 157 

CHAPTER  XVIII. 

Treatment  of  Wounds. 

Asepsis.  Arrestation  of  Hemorrhage.  Coaptation.  Drainage.  Physiolo- 
gical Rest.     Dressings 168 

CHAPTER  XIX. 

Gunshot  Wounds. 

Diagnosis.  Effects  of  Dififerent  Missiles.  Explosive  Efifect.  Hydraulic 
Pressure.  Compressed  Air,  or  Projectile  Air.  Rotation  of  the  Bullet. 
Deformation.     Heating.     Primary  Fatal  Hemorrhage 173 

CHAPTER  XX. 

Gunshot  Wounds  of  the  Face. 

Classification— Of  the  Nose— Of  the  Malar— Of  the  Upper  Jaw— Of  the 
Mandible.      Symptoms.     Treatment 184 

CHAPTER  XXL 

Fractures  of  the  Inferior  Maxilla. 

Definition.  Fractures  of  the  Alveolar  Process.  Of  the  Body  of  the  Lower 
Jaw.  Displacements.  Lines  of  Fracture.  Symptoms.  Diagnosis. 
Prognosis    198 

CHAPTER  XXII. 

Fractures  of  the  Inferior  Maxilla  (Continued). 

Treatment.    Abscess  of  the  Jaws 208 

CHAPTER  XXIIL 

Fractures  of  the  Superior  Maxilla  and  Upper  Bones  of  the  Face  224 

CHAPTER  XXIV. 

Delayed  Union  and  Ununited  Fractures. 
Causes.    Treatment  of  Delayed  Union— Of  Ununited  Fractures 239 


Xii  CONTENTS. 

CHAPTER  XXV. 

Dislocation  of  the  Inferior  Maxilla. 

Definition.  Dislocations  of  the  Lower  Jaw — Causes — Symptoms — Treat- 
ment.    Subluxation  of  the  Jaw — Causes — Treatment 248 

CHAPTER  XXVI. 

Ankylosis  of  the  Jaws. 

Definition.  Temporary  Ankj'losis — Causes — Treatment.  Permanent  An- 
kylosis— Causes — Diagnosis — Treatment — Mechanical  Treatment — Surgi- 
cal Treatment 255 

CHAPTER  XXVII. 

Periostitis  of  the  Jaws. 

Definition.  Causes.  Symptoms.  Acute  Diffuse  Periostitis — Causes — Treat- 
ment. Mercurial  Periostitis — Symptoms — Treatment.  Chronic  Perios- 
titis of  the  Jaws 264 

CHAPTER  XXVIII. 

Necrosis  of  the  Jaws. 
Definition.     Causes.     Symptoms.     Treatment 268 

CHAPTER  XXIX. 

Necrosis  of  the  Jaws  (Continued). 

Exanthematous  Necrosis — Symptoms — Treatment.  Mercurial  Necrosis — 
Treatment.  Arsenical  Necrosis — Treatment.  Phosphorus  Necrosis — 
Symptoms — Treatment.  Syphilitic  Necrosis — Symptoms — Treatment. 
Reproduction  of  Bone 273 

CHAPTER  XXX. 

Stomatitis. 

Definition.  Stomatitis  Simplex — Symptoms — Treatment.  Stomatitis  Ca- 
tarrhalis — Causes — Symptoms — Treatment.  Stomatitis  Aphthosa — 
Treatment.     Stomatitis  Ulcerosa — Causes — Symptoms — Treatment 282 

CHAPTER  XXXI. 

Leucoplakia. 

Definition.  Varieties.  Etiology.  Symptoms.  Diagnosis.  Pathology.  Prog- 
nosis.    Treatment 294 

CHAPTER  XXXII. 

Surgical  Tuberculosis. 

Tuberculosis — Avenues    of    Infection — Pathology 308 

CHAPTER  XXXIII. 

Surgical  Tuberculosis  (Continued). 

Tuberculosis  of  Bone — Symptoms  and  Diagnosis — Dififerential  Diagnosis — 

Prognosis — Treatment    318 


CONTENTS.  xiii 

CHAPTER   XXXIV. 
Surgical  Tuberculosis  (Continued). 

'  PAGE 

Tuberculosis  of  the  Skin — Pathology.  Tuberculosis  of  the  Skin  of  the 
Face — Of  the  Mucous  Membrane  of  the  Mouth — Of  the  Tongue  and 
Pharyn.x.     Dififerential    Diagnosis.     Prognosis.     Treatment 331 

CHAPTER   XXXV. 

Actinomycosis  Hominis. 

Definition.     Etiology.     Pathology.     Symptoms    and    Diagnosis.      Prognosis. 

Treatment 344 

CHAPTER   XXXVI. 
Diseases  of  the  Maxillary  Sinus. 

Suppurative  Inflammation  of  the  Maxillary  Sinus — Etiology.  Devitalized 
Pulps.  Alveolar  Abscesses.  Malposed  Teeth.  Foreign  Bodies.  Trau- 
matic Injuries.     Catarrhal  Affections.     Mucous   Engorgements 358 

CHAPTER  XXXVIL 

Diseases  of  the  ]\Iaxillary  Sinus  (Continued). 

Suppuration  of  the  Antrum  of  Highmore — Symptoms — Diagnosis — Diflfer- 

ential  Diagnosis — Prognosis — Treatment  374 

CHAPTER  XXXVIII. 

Diseases  of  the  IMaxillary  Sinus  (Continued). 

Syphilitic  Ulceration  of  the  Antrum  of  Highmore — Diagnosis — Differential  ■ 
Diagnosis — Treatment.    Necrosis  of  the  Walls  of  the  Maxillary  Sinus — 
Symptoms — Treatment    382 

CHAPTER  XXXIX. 

Cystic  Tumors  of  the  Maxillary  Sinus. 

Mucous  Cysts  of  the  Antrum — Sj-niptoms  and  Diagnosis — Prognosis — 
Treatment.  Polypus  of  the  Antrum — Symptoms  and  Diagnosis — Prog- 
nosis— Treatment    389 

CHAPTER  XL. 

Diseases  of  the  S.\liv.\ry  Glands. 

Inflammation  of  the  Parotid  Gland — Symptoms  and  Diagnosis — Prognosis 
— Treatment.  Salivary  Calculi  —  Causes — Symptoms  —  Diagnosis — - 
Treatment.      Salivary   Fistulje— Causes — Diagnosis — Treatment 394 

CHAPTER  XLI. 

Neuralgia. 

Definition.  Causes.  Predisposing  Causes.  Exciting  Causes.  Trifacial 
Neuralgia — Symptoms — Causes — Diagnosis    401 


XIV  CONTENTS. 

CHAPTER   XLII. 
Treatment  of  Trifacial  Neuralgia.                            page 
Therapeutic  Treatment — Surgical  Treatment 412 

CHAPTER  XLIII. 

Congenital  Fissures  of  the  Lip  and  the  Vault  of  the  Mouth. 

Origin — Non-Union  of  Superior  and  Lateral  Processes — Arrested  Develop- 
ment— Faulty  Nutrition — Heredity — Maternal  Impressions.      Prognosis  420 

CHAPTER  XLIV. 

Congenital  Fissures  of  the  Lip  and  the  Vault  of  the  Mouth. 
(Continued.) 
Surgical     Treatment — Operations.       Hare-Lip — Uranorrhaphy — Staphylor- 
rhaphy— Mechanical  Treatment    431 

CHAPTER  XLV. 

Tumors. 

Definition.     Origin.     Germinal  Layers.     Structure.     Classification 449 

CHAPTER  XLVL 

Tumors  of  the  Face,  Mouth,  and  Jaws. 

Epithelial  Tumors.  Papillomata — Definition.  Cornu  Cutaneum — Treat- 
ment   460 

CHAPTER  XLVn. 

Epithelial  Tumors  (Continued). 

Adenomata — Definition — Causes.  Adenoma  of  the  Skin — Diagnosis  and 
Symptoms.  Adenoma  of  the  Palate — Diagnosis  and  Symptoms — Prog- 
nosis— Treatment.  Adenoma  of  the  Tongue — Diagnosis  and  Symptoms 
— Prognosis — Treatment.  Adenoma  of  the  Salivary  Glands — Diagnosis 
and    Symptoms — Prognosis — Treatment 470 

CHAPTER  XLVIIL 
Cystomata. 
Definition.     Cysts  of  the  Jaws  and  Teeth — Diagnosis — Prognosis — Treat- 
ment      485 

CHAPTER  XLIX. 

Cystomata  (Continued). 

Multilocular  Cysts  of  the  Jaws — Definition — Causes — Diagnosis  and  Symp- 
toms— Prognosis — Treatment    493 

CHAPTER  L. 

Cystomata  (Continued). 

Dentigerous  Cysts — Causes.     Dermoid   Cysts.     Diagnosis  and  Symptoms. 

Differential  Diagnosis.     Prognosis.     Treatment 500 


CONTENTS.  XV 

CHAPTER  LI. 

Carcinomata. 

PAGE 

Definition.  Origin.  Varieties  and  Structure.  Squamous-Celled — Cylin- 
drical-Celled— Glandular.  Infection  and  Dissemination.  Prevalence. 
Sex.     Age   514 

CHAPTER  LII. 

Carcinomata  (Continued). 

Causes — Heredity — Bacteria.     Exciting  Causes.     Diagnosis  and  Symptoms. 

Prognosis.     Treatment  529 

CHAPTER   LIII. 

Carcinomata  (Continued). 

Carcinoma  of  the  Skin.     Of  the  Face — Diagnosis — Prognosis — Treatment.  539 

CHAPTER  LIV. 

Carcinomata  (Continued). 

Carcinoma  of  the  Lip — Diagnosis — Prognosis — Treatment 553 

CHAPTER  LV. 

Carcinomata  (Continued). 

Carcinoma  of  the  Buccal  Mucous  Membrane  and  Jaws.     Of  the  Antrum — 

Treatment    564 

CHAPTER  LVI. 

Carcinomata  (Continued). 

Carcinoma  of  the  Pharynx.  Of  the  Palate  and  Uvula — Symptoms — Treat- 
ment. Carcinoma  of  the  Tongue — Causes — Symptoms  and  Diagnosis 
— Prognosis — Treatment.  Carcinoma  of  the  Tonsils — Symptoms — 
Prognosis — Treatment.  Carcinoma  of  the  Salivary  Glands — Treat- 
ment      571 

CHAPTER  LVII. 

Mesoblastic  Tumors. 

Fibromata — Definition — Origin — Varieties — Causes.     Fibroma  of  the  Gums 

— Diagnosis — Prognosis — Treatment.     Fibroma  of  the  Skin 586 

CHAPTER   LVIII. 

Chondromata. 

Definition.     Diagnosis.     Prognosis.     Chondroma  of  the  Salivary  Glands..  596 

CHAPTER  LIX. 

Osteom.\ta. 

Definition.     Compact  Osteomata.     Cancellous  Osteomata.     Treatment 603 


XVI  CONTENTS, 

CHAPTER   LX. 
Angiomata. 

I'AC.K 

Definition.     Origin.     Diagnosis.     Treatment 6i6 

CHAPTER   LXI. 

Sarcomata. 

Definition.  Origin.  Varieties  and  Structure.  Round-Celled  Sarcoma. 
Spindle-Celled  Sarcoma.  Myeloid  Sarcoma.  Alveolar  Sarcoma. 
Melano-Sarcoma.  Mixed-Cell  Sarcoma.  Retrogressive  Changes.  In- 
fection and  Dissemination.  Causes.  Diagnosis  and  Symptoms.  Prog- 
nosis.    Treatment    625 

CHAPTER   LXII. 

Sarcomata  (Continued). 

Sarcoma    of    the    Jaws — Periosteal — ^luco-Periosteal — Endosteal — Odonto- 

Sarcoma.     Sarcoma  of  the  Salivary  Glands 646 

CHAPTER  LXIII. 
Treatment  of  Sarcoma  of  the  Jaws 659 

CHAPTER  LXIV. 

Odontomata. 

Definition.  Fibrous  Odontomes.  Cementomes.  Compound  Follicular 
Odontomes.  Radicular  Odontomes.  Composite  Odontomes.  Diag- 
nosis.    Prognosis.     Treatment 667 

CHAPTER  LXV. 
Odontomata  (Continued). 

Causes.  Aberrations  in  Development  and  Position.  Diagnosis  and  Symp- 
toms.     Prognosis.     Treatment 687 


CHAPTER  LXVI.  • 

Retention  Cysts. 

Cysts  of  the  Skin.  Comedo — Causes — Treatment.  Milium — Causes — 
Treatment.  Sebaceous  Cysts  or  Wens — Causes — Prognosis — Treat- 
ment. Sudoriparous  Cysts — Treatment.  Cysts  of  the  Mucous  Mem- 
brane. Muciparous  Cysts — Causes — Diagnosis  and  Symptoms — Treat- 
ment. Mucous  Cysts  of  the  Antrum  of  Highmore — Treatment.  Cysts 
of  the  Salivary  Glands.  .  Ranula — Causes — Diagnosis  and  Symptoms — 
Prognosis — Treatment    694 

Index    7^5 


Injuries  and  Surgical  Diseases  of  the 
Face,  Mouth,  and  Jaws. 


PART  I. 


CHAPTER    I. 

SURGICAL   BACTERIOLOGY. 

The  promulgation  of  the  Germ  Theory  of  disease  was  the  begin- 
ning of  a  great  revohition  in  the  practice  of  both  medicine  and  surgery; 
a  revolution  which  at  the  present  time  is  still  going  on  with  increasing 
success,  recording  victory  after  victory,  and  constantly  invading  new 
territory  heretofore  occupied  by  dread  pestilence  and  epidemic  disease, 
and  tearing  from  their  grasp  trophies  in  the  form  of  the  discovery  of 
the  causation  of  these  dreaded  maladies,  and  of  the  means  wherewith 
to  successfully  combat  them.  The  application  of  the  principle  of  the 
germ  theory  of  disease  has  had  its  greatest  successes  in  the  department 
of  surgery;  in  fact,  it  has  placed  modern  surgerv^  upon  the  exalted  pin- 
nacle which  it  occupies  to-day.  Without  the  discovery  of  the  pyogenic 
bacteria  and  of  the  other  pathogenic  forms  now  known  to  science,  and 
without  a  knowledge  of  the  principles  of  modern  antiseptics,  much  of 
the  success  which  has  been  achieved  in  surgery  during  the  last  two 
decades  would  still  be  an  impossibility. 

"In  the  light  of  the  germ  theon.^  disease  may  be  considered  to  be 
a  battle  between  the  organism  and  an  invading  army  of  parasites,  while 
the  treatment  of  diseases  resolves  itself  into  the  question  of  how  best  to 
assist  the  organism  in  overcoming  the  enemy  which  has  entered  its 
territory."     (Gradle.) 

Parasites. — Definition.  Parasites  are  plants  or  animals  which  live 
upon  other  plants  or  animals. 

Parasites  may  belong  to  either  the  animal  or  the  vegetable  king- 
dom. In  the  early  history  of  bacteriology  there  was  great  diffi- 
culty in  classing  them.     In  most  instances  the  parasites  which  enter 


2  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

the  animal  organism  are  microscopic  in  size ;  hence  they  are  re- 
ferred to  as  micro-organisms,  microbes,  or  bacteria.  Bacteria  are  now 
generally  considered  as  belonging  to  the  vegetable  kingdom.  The 
bacteria  belong  to  the  fission  plants  known  as  the  Schizophyta  or 
Schizophytes,  a  division  of  the  Thallophyta  including  those  varieties 
which  multiply  by  fission  or  division.  These  are  divided  into  two  sub- 
classes, those  which  possess  chlorophyll,  namely,  the  Cyanophyce<2 
(usually  referred  to  as  Algce),  and  those  having  no  chlorophyll,  or  the 
Schizomycetes  (usually  referred  to  as  Fungi).  "Many  of  these  are 
so  small  as  to  approach  the  limits  of  visibility,  even  when  the  highest 
powers  of  the  microscope  are  used."  When  located  in  the  animal 
tissues  they  are  demonstrated  with  great  difficulty,  and  only  by  the 
aid  of  special  staining  agents  can  they  be  differentiated  from  the  cel- 
lular elements  of  the  tissues ;  even  then  doubt  sometimes  shadows  the 
certainty  of  the  demonstration,  and  it  becomes  necessary  to  make 
experimental  cultivations  of  the  products  of  tissue  disintegration  in  the 
case  before  a  positive  diagnosis  can  be  reached.  The  sphcBrohacteria, 
or  micrococci,  are  the  smallest  of  all  the  bacterial  forms.  Fig.  i 
represents  some  of  the  common  forms  of  bacteria. 

These  organisms,  the  bacteria,  are  classed  by  Pasteur  under  two 
general  heads,  namely :  Aerobes  and  Anaerobes. 

The  aerobic  microbes  require  the  oxygen  of  the  atmosphere  in 
order  to  maintain  life,  and  therefore  live  upon  the  surfaces  of  sub- 
stances.    The  yeast  fungi  are  examples  of  aerobic  microbes  (Fig.  2). 

The  anaerobic  microbes  do  not  require  oxygen  to  maintain  life, 
and  therefore  live  beneath  the  surfaces  of  liquids  and  inside  of  living 
bodies.  The  Bacterium  tetani  is  an  example  of  the  anaerobic 
microbes. 

The  greater  portion  of  the  bacteria  are  aerobic.  Some  of  them  are 
so  dependent  upon  oxygen  that  the  slightest  diminution  in  the  supply 
is  sufficient  to  arrest  or  completely  prevent  their  development.  These 
have  been  called  obligate  aerobic  bacteria.  Others  grow  in  media 
rich  in  oxygen,  and  also  where  there  is  no  oxygen.  These  have  been 
termed  facultative  aerobic  bacteria.  Nearly  all  the  pathogenic  forms  of 
bacteria  belong  to  the  facultative  variety.  The  tissues  of  the  body  con- 
tain a  certain  amount  of  oxygen,  but  this  is  soon  consumed  by  the 
micro-organisms  in  their  growth;  consequently  they  would  die  if  they 
did  not  have  the  faculty  of  living  without  oxygen  under  certain  condi- 
tions. The  anaerobic  bacteria  are  exceedingly  rare  among  the  patho- 
genic forms.  The  presence  of  oxygen  retards  their  growth  or  com- 
pletely arrests  their  development.  The  spores,  however,  maintain  their 
vitality  in  oxygen  for  a  considerable  period  of  time. 

Pasteur  discovered  that  when  artificial  cultures  of  certain  patho- 
genic bacteria  were  exposed  for  a  considerable  time  to  oxygen,  gener- 


SURGICAL    BACTERIOLOGY. 


Fig.    I. 


A 


.'}• 


ittite 


•V 


OQggQOOO 


Various  Forms  of  Bacteria. 
a,  Cocci,  d,  Diplococci  c,  Cluster-cocci  (Staphylococci),  d,  Coccus  chains  (Streptococci,  Toru- 
la).  ^,  Surface-shaped  colonies  (Merismopedia).  /",  Pocket-shaped  colonies  (Sarcina).  ^,  a  double 
coccus  chain  produced  by  a  single  fissation  of  each  member  in  a  direction  at  right  angles  to  the  long 
axis  of  the  chain,  h,  Vibriones.  t,  k,  Spirilla.  /,  Spirochsetes.  m,  Spiromonades.  n,  Spirulina. 
o,  Cladothrix.  fi,  Rods  (bacilli).  ^,  Clostridium,  r,  Leptothrix  (threads),  r',  Articulated  threads. 
J,  Rhabdomonas.    t,  u,  v,  Zoogloea.     (In  part  after  Fliigge  &  Zopf.) 


Fig.  2. 


Various  Forms  of  Yeast  Fungi. 
a,  Colonies  of  round  cells   (Saccharomyces  conglomeratus?).   d,  Single  cells  of  dilTerent  forms 
partly  forming  daughter-cells,   c,  Cylindrical  cells  of  pellicle-fungus  (Saccharomyces  mycoderma). 


4  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

ally  from  three  to  eight  months,  the  virus  became  very  much  attenu- 
ated. His  first  experiments  were  with  the  microbe  of  chicken  cholera 
and  the  bacillus  of  anthrax.  He  found  that  a  chicken  inoculated  with 
the  weak  cultures  of  the  chicken  cholera  bacillus  was  rendered  immune 
to  the  action  of  the  virulent  virus,  and  that  the  attenuated  culture  of 
the  anthrax  bacillus,  prepared  in  the  same  manner,  rendered  sheep 
immune  to  anthrax,  or  if  they  contracted  the  disease  after  inoculation, 
it  appeared  in  only  a  very  mild  form. 

Paul  Bert  has  shown  that  oxygen,  under  a  pressure  of  from  20  to 
40  centimeters,  destroys  the  vitality  of  the  anthrax  bacillus. 

The  Microscopic  Study  of  Bacteria. — In  order  to  successfully 
study  bacteria,  a  good  quahty  of  microscope,  with  oil  immersion  lenses 
and  Abbe  condenser,  is  an  absolute  necessity.  Anilin  dyes  are  gen- 
erally used  to  stain  the  micro-organisms,  which  are  often  very  tena- 
cious in  their  hold  upon  the  staining  fluids,  thus  making  it  possible  to 
discover  the  minute  forms  which  would  otherwise  be  invisible. 

Portions  of  tissue  which  it  is  desired  to  examine  for  the  presence 
of  bacteria  are  first  cut  into  small  fragments,  about  a  quarter-inch 
square,  and  placed  in  absolute  alcohol.  It  is  best  to  do  this  imme- 
diately, that  the  tissue  may  be  preserved  in  the  condition  which  it  pre- 
sented when  removed  from  the  body.  The  alcohol  should  be  changed 
as  often  as  twice,  and  at  the  end  of  forty-eight  hours  the  specimen  will 
be  ready  to  be  cut  into  sections.  These  must  be  cut  very  thin,  and  at 
once  placed  in  a  dilute  solution  of  fuchsin  or  gentian  violet,  and  allowed 
to  remain  from  one  to  six  hours.  They  are  afterward  decolorized  in 
water  which  has  been  acidulated  with  acetic  acid,  washed  in  water,  then 
dehydrated  with  alcohol,  clarified,  and  mounted  in  Canada  balsam. 

Double  staining,  or  contrast  staining,  is  sometimes  used  for  the 
purpose  of  better  definition.  By  this  means  the  micro-organisms  are 
stained  one  color,  and  the  tissues  a  decidedly  different  one,  but  always 
of  a  paler  hue. 

The  examination  of  blood,  pus,  urine,  and  sputa  is  accomplished 
by  first  evaporating  a  film  of  the  material  upon  a  cover-glass,  fixing, 
and  treating  the  cover-glass  as  a  section.  Ziehl's  method  of  exam- 
ining urine  for  the  tubercle  bacillus  is  to  place  the  cover-glass,  which 
has  been  prepared  by  evaporating  one  or  two  drops  of  urine  upon  it, 
in  the  following  solution,  previously  warmed,  allowing  it  to  remain 
from  five  to  ten  minutes : 

Fuchsin,  i  gram; 

Carbolic  acid  solution  (5  per  cent.),  80  c.c; 

Alcohol  (95  per  cent.),  20  c.c. 

It  is  afterward  decolorized  with  a  5  per  cent,  solution  of  sulfuric 
acid,  which  effectually  removes  the  coloring  matter  from  everything 


SURGICAL    BACTERIOLOGY.  5 

but  the  micro-organisms.  After  washing  with  distilled  water,  it  is 
placed  in  a  watery  solution  of  methyl  blue  for  five  minutes,  again 
washed  in  distilled  water,  dried,  and  mounted  in  Canada  balsam.  By 
this  method  the  bacilli  take  a  red  stain,  while  the  deposit  in  which  they 
are  held  is  colored  blue.  The  same  general  methods  are  applicable  in 
the  examination  of  sputa  from  phthisical  patients. 

Grain's  Method. —  (a)  Place  a  cover-film  in  absolute  alcohol  for 
one  or  two  minutes. 

(b)  Stain  in  anilin  gentian  violet  for  one  or  two  minutes. 

(c)  Remove  superfluous  stain  by  draining. 

(d)  Now  place  in  Gram's  solution  of  iodin  for  one-half  to  one 
minute, — until  the  specimen  turns  black. 

(e)  Soak  up  the  superfluous  iodin  solution. 

(f)  Wash  in  alcohol  until  the  film  is  almost  colorless, — until  no 
more  stain  comes  away.     Dry  and  mount  in  xylol  balsam. 

(g)  If  to  double  stain,  pass  quickly  through  a  dilute  alcoholic 
solution  of  eosin.  The  leucocytes  and  ground  substance  will  be  col- 
ored pink,  the  gonococcus  and  also  the  chromilin  violet. 

(Ji)  Wash  in  water;  examine  if  deep  enough.  T)ry  thoroughly 
and  mount  in  xylol  balsam.     Examine  with  oil  immersion. 

Formula. — Gentian  Anilin  Wafer,  i.  Mix  4  c.c.  anilin  oil  with 
100  c.c.  distilled  water.     Shake  for  one  or  two  minutes. 

2.  Filter  resulting  emulsion  through  filter-paper  moistened  with 
distilled  water. 

3.  To  100  c.c.  of  anilin  water  add  11  c.c.  of  a  concentrated  alco- 
holic solution  of  gentian  violet.  Shake.  Mix  thoroughly.  Always 
filter  before  using.  This  does  not  keep  well,  consequently  only  small 
quantities  should  be  prepared  at  a  time. 

Gram's  Iodin  Solution. 

Iodin  crystals,  i  gram; 
lodid  potassium,  2  grams; 
Distilled  water,  300  c.c. 

Functions  of  Bacteria. — Certain  species  of  bacteria  are  disease- 
producing,  or  pathogenic;  others  are  color-producing,  or  chromogenic. 
Another  species  is  ferment-producing,  or  zymogenic;  another  is  aero- 
genic  or  gas-producing;  other  forms  are  saprogenic — ^these  are  en- 
dowed wdth  intense  putrefactive  properties ;  while  still  others  have  as 
yet  no  discovered  function. 

^^^hen  arranging  bacteria  according  to  their  relation  to  disease,  it 
is  customary  to  class  them  under  two  general  heads : 

First.  N on- pathogenic,  or  those  which  do  not  as  a  direct  cause  pro- 
duce disease. 

Second.  Pathogenic,  or  those  which  are  the  direct  cause  of  disease. 


6  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

Fermentation  and  putrefaction  are  the  results  of  the  g^rowth  of 
micro-organisms  in  the  substances  which  ferment  or  putrefy. 

Among  the  non-pathogenic  micro-organisms  are  included  the 
saprophytic  germs.  These  organisms,  which  may  become  indirect 
causes  of  disease,  can  live  and  grow  only  in  dead  and  dying  tissues. 
Organisms  of  this  character  entering  a  wound  in  which  there  are  pent- 
up  discharges  and  dying  tissues,  increase  with  great  rapidity,  and  pro- 
duce certain  substances  of  a  poisonous  and  irritating  character,  called 
ptomaines,  the  absorption  of  which  by  the  system  gives  rise  to  symp- 
toms which  are  denominated  as  septic  intoxication,  ptomaine  -fever,  or 
septicemia. 

Pathogenic  micro-organisms  grow  and  flourish  in  dead  and  dying 
matter,  and  invade  the  living  tissues  and  destroy  them.  They  also 
enter  the  circulation  by  direct  inoculation  through  wounds  and  abra- 
sions, and  are  carried  to  all  parts  of  the  body,  and  wherever  deposited 
increase  in  numbers  with  amazing  rapidity,  forming  fresh  foci  for  the 
production  of  poisonous  and  irritating  substances.  The  chief  differ- 
ence therefore  between  the  saprophytes  and  pathogenic  germs  is  that 
the  former  act  as  indirect  causes  of  disease  by  the  production  of  poison- 
ous substances  which  are  absorbed  by  the  system,  but  they  have  no 
power  to  penetrate  the  tissues  or  enter  the  circulation ;  while  the  latter 
possess  this  power,  and  act  as  direct  disease-producing  agents. 

The  pathogenic  micro-organisms  may  be  divided  again  into  two 
general  classes: 

First.  Micrococci. 

Second.  Bacilli. 

Each  of  these  classes  has  been  divided  and  subdivided  by  the  bac- 
teriologist into  an  almost  endless  variety.  This  classification  is  the 
result  of  a  thorough  and  careful  study  as  to  their  size,  form,  and  length, 
their  growth,  groupings,  and  action  in  the  various  culture-media,  their 
chemical  reaction,  the  color  imparted  to  the  culture-media,  their  sus- 
ceptibility to  the  various  staining  agents,  and  their  action  upon  fer- 
mentable substances  and  living  organisms. 

New  forms  of  bacteria  are  constantly  being  discovered,  and  further 
research  into  the  life  and  habits  of  old  forms  develops  new  features  and 
modes  of  action  which  a  little  while  before  had  not  been  dreamed  of, 
while  the  etiology  of  certain  diseases  which  were  before  considered  as 
obscure  are  one  by  one  being  cleared  up  by  the  discovery  of  a  specific 
microbe,  which,  when  introduced  into  the  system  in  sufficient  quanti- 
ties, will  produce  the  disease.  It  has  been  recently  announced  that 
Kitasato  has  discovered  the  plague  bacillus,  and  that  it  resembles  the 
micro-organism  of  chicken  cholera. 

The  Micrococcus  is  an  individual  bacterium,  the  smallest  of  all  the 
bacterial  forms,  having  spheric  elements — tiny,  globe-like  masses  of 


SURGICAL    BACTERIOLOGY.  7 

matter in  some  instances  isolated,  in  others  united  in  twos  or  in  larger 

numbers,  or  disposed  in  chains  or  chaplets,  or  deposited  in  masses  of 
zoosilea, — a  gelatinous  matrix  secreted  by  the  bacteria  themselves. 
{a,  Fig.  I.)     ^^'hen  united  in  twos  they  are  called  Diplococci  (b,  Fig.  i). 

Fig.  3. 


DiPLOCOCCUS  Pneumoni.b  from  Lung.    X 

Fig.  4. 


Tetanus  Bacillus. 


Sometimes  they  are  united  in  such  a  way  as  to  resemble  a  bunch  of 
grapes.  They  are  then  termed  Staphylococci  (c,  Fig.  i).  If  arranged 
in  chains  or  chaplets  they  are  denominated  Streptococci  {d,  Fig.  i). 

The  pneumococcus  or  diplococcus  of  pneumonia  (Fig.  3)  is  a 
good  representation  of  the  diplococci. 


surgery  of  the  face,  mouth,  and  jaws. 
Fig.  5- 


i-^  '     S 


Bacillus  of  Asiatic  Cholera.    X  1200. 


Fig.  6. 


Various  Micro-OrgaxNISms  of  the  Mouth.    Leptothri-x  buccalis,  Micrococci  and 
Bacilli,  etc.    X  1200. 


SURGICAL    BACTERIOLOGY.  n 

The  bacillus  of  tetanus  (Fig.  4)  would  seem  from  its  form,  which 
is  like  a  drum-stick,  to  be  a  combination  of  a  micrococcus  and  a 
bacillus,  but  in  reality  it  is  a  bacillus  with  a  spore  at  one  end. 

The  bacillus  of  cholera  (Fig.  5)  seems  to  be  a  combination  of  the 
same  character,  but  having  a  curved  stem  resembling  a  comma;  hence 
it  has  been  named  the  comma  bacillus,  or  Koch  bacillus,  after  the 
name  of  its  discoverer.  Fig.  6  represents  various  micro-organisms  of 
the  mouth. 

Fig.  7. 


Old  or  Matured. 


OiDiuM  LACTis.    (Milk  Mold. 


The  Bacterium  lactis,  which  is  an  active  agent  in  the  production 
of  dental  caries,  is  a  short,  straight,  rod-like  bacillus.  Its  function  is 
that  of  forming  lactic  acid,  and  it  is  the  organism  that  causes  the 
souring  of  milk.  The  Oidium  lactis  (Fig.  7)  is  common  in  the  mouth. 
The  Leptothrix  buccalis  (Fig.  8),  another  bacterium  frequently 
found  in  the  mouth,  and  associated  with  dental  caries,  is  a  long,  slen- 
der, thread-like  bacillus,  usually  found  grouped  in  masses.  Fig.  9 
shows  the  Leptothrix  gigantige. 


lO 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


One  of  the  difficulties  which  the  bacteriologist  and  the  pathologist 
have  to  meet  is  the  seeming  identity  of  certain  forms  of  bacteria  found 

Fig.  8. 


LKPTOTHRIX    EUCCALIS.      X   1200. 

Fig.  9. 


LEPTOTHRI.K    GIGANTI.^.       /    1200. 


in    diseases    presenting    dissimilar    characteristics ;    for    instance,    the 
Streptococcus   pyogenes    (Fig.    loj    seems    to    be    identical    with    the 


SURGICAL    BACTERIOLOGY. 


I  I 


Streptococcus  of  erysipelas,  the  only  discernible  difference  being  one 
of  size,  the  coccus  of  erysipelas  being  the  larger. 

The  cocci  multiply  only  by  fission  or  division,  a  process  similar  to 
karyokinesis  (Fig.  ii).  The  cell  elongates  prior  to  its  segmentation, 
when  a  constriction  appears  in  the  center,  which  becomes  deeper  and 
deeper  until  complete  division  of  the  cell  into  two  equal  parts  takes 
place.     These  new  cells  soon  attain  the  size  of  the  parent  cell. 


Fig.  10. 


•-?? 


Streptococcus  pyogenes.    X  1200. 


^00  CO  00^ 


Fig.  II. 


O    @ 


Fission  of  Bacteria  (Cocci). 
a  and  d,  Fissation  in  one  direction  ;  b,  in  two  ;  c,  in  three  directions. 


The  staphylococci,  diplococci.  and  streptococci  are  generally 
found  in  the  broken-down  tissue  and  discharges  w^hich  result  from  in- 
flammatory action,  particularly  in  pus  formations. 

The  Bacillus  is  an  individual  bacterium  of  rod-like  form,  and  in- 
cludes all  the  elongated  forms  of  bacteria,  except  such  as  are  spiral  and 
have  a  gyratory  motion,  which  are  classed  with  the  genus  Spirillum. 

A  Spirillum  is  an  individual  bacterium  whose  elements  are  curved, 
often  forming  a  spiral  of  several  turns.     The  comma  bacillus  of  Koch, 


12 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


found  in  the  discharges  of  cholera  patients,  is  a  spirihum,  and  repre- 
sents the  simple  curved  variety;  while  the  spirillum  of  Miller,  found  in 
carious  teeth,  represents  the  spiral  form.  Some  of  the  spirilla  have 
cilia  attached  (Fig.  12). 

Fig.  12. 


Bacilli. 


Spirilla  Cilia.    X  1250. 


Bacilli  are  rigid  or  flexible,  motile  or  non-motile,  and  reproduce 
their  kind  either  by  direct  fission  or  by  endogenous  spore-formation, — 
the  formation  of  a  cell  within  the  body  of  the  parent  cell  (Fig.  13). 
This  process  is  a  very  rapid  one.     Fliigge  observed  the  process  of  seg- 


FlG. 


Spore  Formations  in  Bacilli. 


mentation  in  a  coccus  to  occur  in  twenty  minutes.  Cohn  has  made  the 
calculation  that  if  it  should  take  one  hour  to  complete  the  process  of 
segmentation,  and  for  the  new  cell  to  attain  the  size  of  the  parent  cell, 
one  coccus,  multiplying  by  this  process,  would  in  one  day  produce 
16,000,000  cocci;  at  the  end  of  two  days  281,000,000,000,  while  at  the 


SURGICAL    BACTERIOLOGY.  I3 

end  of  the  third  day  it  would  have  reached  the  enormous  number  of 
46,000,000,000,000. 

The  spore  possesses  an  exceedingly  dense  enveloping  membrane, 
which  protects  it  from  deleterious  external  influences  until  such  time  as 
it  finds  a  soil  favorable  to  its  growth  and  development.  The  parent  cell 
is  usually  enlarged  in  the  center  or  at  one  end  by  the  presence  of  the 
spore,  and  when  the  latter  reaches  its  full  development,  gelatinous 
softening  of  the  cell-membrane  takes  place,  the  cell  breaks  up,  and  the 
spore  is  set  free.  During  the  process  of  development  of  the  spore  into 
a  bacillus  it  loses  its  tough  enveloping  membrane  and  is  therefore  more 
readily  destroyed.  The  majority  of  bacteria  grow  at  a  temperature 
of  37°  C.=:98°  F.  Spores  resist  the  action  of  germicidal  agents  to  a 
much  greater  degree  than  the  bacilli  which  produce  them.  Mature 
bacteria  cannot  resist  a  temperature  of  'j'j°  C,  170°  F.  Most  of  them 
are  destroyed  when  exposed  to  55°  C,  131°  F.,  while  spores  have  been 
known  to  resist  a  temperature  of  100°  to  120°  C,  212°  to  236°  F.  A 
temperature  of  100°  C,  212°  F.,  if  maintained  for  ten  to  fifteen  minutes, 
will  effectually  destroy  the  most  persistent  of  spores. 

Spores  which  have  gained  an  entrance  to  the  body  may  remain 
dormant  for  years,  and  give  rise  to  no  untoward  symptoms  until 
aroused  to  activity  by  conditions  which  favor  their  growth  and  devel- 
opment. Two  conditions  are  necessary  for  the  germination  of  bac- 
teria, viz:  a  certain  amount  of  heat  and  moisture.  Both  must  be  pres- 
ent. The  requisite  amount  of  heat  minus  the  moisture,  or  the  moisture 
without  the  heat,  is  in  neither  case  favorable  to  their  development. 
This  is  eminently  true  in  the  treatment  of  dental  caries  and  devitalized 
teeth;  with  thorough  desiccation  of  the  cavity  of  decay  or  of  the  root- 
canal,  and  the  prevention  of  the  ingress  of  moisture,  caries  will  be  ar- 
rested in  the  one  case,  and  suppuration  prevented  in  the  other.  In  no 
department  of  surgery  is  thorough  antisepsis  more  important  than  in 
operations  upon  the  teeth. 

The  Pyogenic  or  Pus  Microbes. — The  micro-organisms  with  which 
the  surgeon  has  most  frequently  to  contend  are  those  which  cause 
suppuration.  Their  effect  upon  the  inflammatory  exudates,  leucocytes, 
and  cellular  elements  of  the  tissues,  is  one  of  specific  action  by 
which  they  convert  them  into  pus-corpuscles.  They  are  therefore 
called  pyogenic  or  pus-microbes.  Of  these  there  are  several  varieties, 
most  of  them  of  the  globular  or  coccus  form.  The  number  of  bacterial 
forms  which  have  been  found  in  connection  with  surgical  diseases,  and 
fully  identified  as  their  exciting  cause,  is  not  large;  yet  the  statement 
may  be  safely  made  upon  the  basis  of  our  present  knowledge,  that  all 
traumatic  infective  diseases  can  be  traced  to  the  action  of  micro-organ- 
isms which  have  gained  an  entrance  to  the  tissues. 

Koch  lays  down  certain  rules  as  a  crucial  test,  before  the  positive 


14  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

assertion  can  be  made  that  a  particular  organism  is  the  specific  cause 
of  a  disease:  ist,  it  must  be  found  in  all  cases  of  that  disease;  2d,  it 
must  be  found  in  no  other  disease;  3d,  it  must  appear  in  such  quantity 
and  be  so  distributed  that  all  symptoms  can  be  accounted  for  by  its 
presence;  4th,  the  organism  must  be  capable  of  being  isolated  from 
the  diseased  tissues,  and  be  grown  upon  some  of  the  artificial  culture- 
media;  5th,  when  injected  into  an  animal  it  must  be  capable  of  repro- 
ducing the  disease.  All  of  these  conditions  can  rarely  be  fulfilled  in 
many  cases,  yet  when  a  certain  form  or  variety  of  bacteria  is  constantly 
present  in  a  particular  disease,  it  is  pretty  good  evidence  that  it  is  the 
cause  of  that  disease. 

Infection. — The  eft'ect  of  infection  with  the  pyogenic  cocci  will 
always  vary  with  the  number  of  the  microbes  entering  the  tissues, 
the  favorable  or  unfavorable  conditions  of  the  tissues  for  their  growth, 
and  the  general  susceptibility  of  the  organism.  These  facts  have 
been  abundantly  proved  by  repeated  inoculation  experiments  upon 
animals.  Watson  Cheyne  found  that  the  number  of  the  bacteria  in- 
jected makes  a  very  great  difference  in  the  intensity  of  the  symptoms 
and  the  character  of  the  disease.  He  arrived  at  a  general  idea  of  the 
number  of  bacteria  in  a  given  quantity  of  fluid  by  means  of  the  plate 
culture,  the  fluid  having  been  diluted  for  the  purpose;  a  definite  quan- 
tity of  this  fluid  was  injected  into  an  animal,  and  at  the  same  time 
plates  were  made  from  an  equal  quantity.  The  number  of  organisms 
in  the  fluid  injected  was  thus  quite  accurately  determined. 

In  the  case  of  the  Proteus  vulgaris  of  Hauser,  Fig.  14  (a  bac- 
terium commonly  associated  with  putrefaction),  he  found  that  a  dose 
of  i-io  c.c.  of  an  undiluted  culture  contained  about  250,000,000  bac- 
teria, and  when  injected  into  the  muscular  tissue  of  a  rabbit  quickly 
proved  fatal;  while  a  dose  of  1-40  c.c,  containing  about  56,000,000, 
caused  very  extensive  abscess  and  resulted  in  the  death  of  the  animal 
in  from  six  to  eight  weeks.  Doses  which  contained  less  than 
18,000,000  very  rarely  produced  any  effect. 

He  also  demonstrated  that  with  cultures  of  the  Staphylococcus 
pyogenes  aureus  it  was  necessary  to  inject  a  dose  sufficient  to  include  at 
least  1,000,000,000  cocci  into  the  muscle  of  the  rabbit  to  procure  a 
speedy  fatal  effect;  while  a  dose  of  250,000,000  caused  the  formation 
only  of  a  small  circumscribed  abscess.  The  Staphylococcus  pyogenes 
albiis  was  found  to  produce  the  same  results,  but  with  somewhat 
larger  doses. 

Another  interesting  fact  discovered  by  the  same  investigator  was, 
that  concentration  of  the  bacterial  material  in  a  certain  locality  was 
necessary  to  produce  the  most  marked  results.  Dividing  the  dose  and 
injecting  it  at  different  times  or  in  different  locations  at  the  same  time, 
did  not  produce  the  same  results  as  when  it  was  all  injected  into  a 
smgle  locality. 


SURGICAL    BACTERIOLOGY. 


15 


The  susceptibility  of  the  human  organism  to  the  action  of  the 
pyogenic  cocci  is  not  very  great,  and  the  results  produced  by  them  will 
vary  according  to  the  numbers  introduced  and  the  conditions  of  the 
tissues  at  the  time.  The  introduction  of  small  numbers  of  these 
microbes,  if  accompanied  with  the  toxic  substances  which  are  present 
in  the  virulent  cultures,  is  more  liable  to  cause  suppuration  than  when 
not  so  accompanied,  and  the  extent  of  the  inflammatory  process  will 
bear  a  close  relation  to  the  quantity  and  quality  of  these  substances. 
(Warren.) 

Fig.  14 


Bacillus  proteus  vulgaris  of  Hauser.    X  1000. 


The  entrance  of  a  few  pus-microbes  into  a  wound  may  be  entirely 
harmless  unless  the  conditions  are  favorable  for  their  growth  and  mul- 
tiplication. Such  conditions  would  be  represented  by  retained  exuda- 
tions, a  blood-clot,  or  irritation  of  the  wound  from  sutures  or  dressings. 

Pathogenic  micro-organisms  are  frequently  found  in  the  blood  of 
healthy  living  persons,  but  it  remains  a  disputed  question  as  to  whether 
they  can  exist  in  the  body  without  causing  disease.  Experiment  has 
proved  that  pathogenic  micro-organisms  are  harmless  so  long  as  they 
remain  in  the  circulating  blood,  but  if  they  become  localized  then  their 
specific  pathogenic  action  becomes  manifest.  Pathogenic  spores  may 
remain  in  the  healthy  body  for  an  indefinite  period,  in  a  quiescent  state, 
or  until  some  pathologic  change  takes  place  in  the  tissues,  furnishing 
the  soil  and  conditions  for  their  germination. 

Fodor  injected  pathogenic  bacteria  into  the  circulation  of  rabbits, 


i6 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


for  the  purpose  of  studying  their  effect  upon  the  tissues  and  the  mode 
of  elimination.  In  a  majority  of  instances  he  found  that  they  had  en- 
tirely disappeared  from  the  blood  at  the  end  of  twenty-four  hours,  and 
he  is  of  the  opinion  that  they  were  destroyed  by  the  blood-corpuscles. 
Metchnikoff  advanced  the  theory  that  the  leucocytes,  which  are  always 
present  in  large  numbers  in  acute  inflammatory  processes,  and  which 
he  denominated  phagocytes,  have  the  power  of  appropriating  and 
destroying  the  invading  bacteria. 

The  relative  frequency  of  the  presence  of  pyogenic  cocci  in  cases 
of  suppuration  in  the  human  species  is  shown  by  Steinhaus  to  be  as 
follows:  Out  of  330  cases  reported  by  different  observers,  the  sta^ny- 
lococci  were  present  in  66.5  per  cent.;  the  streptococci  in  20.4  per  cent.. 


5i      I4  ^^}.f^u  y 


Staphylococcus  pyogenes  aureus.     X  1200. 


and  a  mixture  of  these  two  forms  in  9.5  per  cent.,  while  the  tenuis  was 
present  in  only  i  per  cent.,  and  the  other  forms  even  more  rarely.  In 
other  words,  pus  micro-organisms  were  present  in  97.4  per  cent,  of 
cases. 

The  Staphylococcus  pyogenes  aureus  (Fig.  15),  yellow  cocci, — so 
called  from  the  fact  that  it  is  arranged  in  clusters,  and  gives  a  yellow 
color  when  cultivated  in  beef-gelatin, — is  the  most  common  of  all  the 
pus-microbes.  It  is  globular  in  shape,  and  its  diameter  ranges  from 
0.7  to  0.87  micro- millimeter.  The  size  depends  upon  the  age  of  the 
coccus  and  the  soil  in  which  it  grows.  It  multiplies  by  fission,  but  the 
line  of  division  is  difBcult  to  make  out.  It  grows  readily  upon  beef 
gelatin  at  the  house  temperature,  but  is  more  active  when  grown  in  a 
temperature  like  that  of  the  body,  and  does  not  require  a  large  amount 
of  oxygen  to  maintain  a  vigorous  growth.  It  has  the  power  of  lique- 
fying gelatin  by  virtue  of  its  peptonizing  action,  and  it  receives  the 
color  of  nearly  all  the  staining  agents  very  readily,  and  is  well  adapted 


SURGICAL    BACTERIOLOGY.  I7 

to  the  Gram  method.  It  is  also  very  tenacious  of  life,  and  requires  to 
be  subjected  to  the  boiling  temperature  for  several  minutes  in  order  to 
destroy  its  vitality.  Cultures  of  this  coccus  have  a  peculiar  and  dis- 
agreeable odor  like  that  of  sour  paste.  It  is  found  abundantly  outside 
of  the  body.  Its  most  common  seat  is  the  superficial  layers  of  the  skin, 
particularly  in  those  parts  of  the  body  which  are  kept  moist,  like  the. 
axill?e,  between  the  buttocks,  etc.;  also  under  the  free  ends  of  the 
finger-nails;  in  the  mucus  of  the  nasal  passages,  pharynx,  mouth,  and; 
digestive  tract.  It  has  likewise  been  found  in  the  air,  especially  of 
lnoc-«iital  wards  which  were  in  an  unsanitary  condition;  in  garden  soil>. 
in  the  dirt  of  the  streets,  in  dirty  dish-water,  and  in  fact  almost  every- 
where. 

The  SfapJiylococais  pyogenes  alhus — white  coccus — cannot  be  dis- 
tinguished from  the  aureus,  except  that  it  does  not  develop  the  yellow 
or  golden-colored  pigment.  It  would  seem  to  be  a  variety  of  the 
aureus  but  for  the  fact  that  it  cannot  be  so  cultivated  as  to  give  the 
color  of  the  yellow  coccus.  It  always  maintains  its  white  color  in  any 
culture-medium  upon  which  it  will  grow.  It  has  the  power  of  lique- 
fying gelatin.  It  is  found  less  often  than  the  aureus,  is  not  so  virulent, 
and  the  disturbances  in  the  tissues  caused  by  its  presence  are  less  pro- 
nounced. 

The  Staphylococcus  viridis  Uavescens ,—gxetmsh.-ye\\o^  coccus, — 
found  in  the  vesicles  of  varicella,  is  an  exceedingly  rare  variety. 
According  to  Babes  it  occupies  an  intermediate  position  between  the 
aureus  and  albus.  The  cocci  are  irregular  in  shape,  and  larger  than 
the  aureus.  When  cultivated  upon  agar-agar,  it  forms  a  delicate  film. 
Its  characteristic  color  is  a  greenish-yellow  pigment. 

The  Staphylococcus  pyogenes  citreus — lemon-colored  coccus.  This 
variety  seems  to  be  in  all  respects  like  the  aureus  and  albus  in  its 
behavior,  with  the  exception  that  it  develops  a  pale-yellow  or  lemon- 
yellow  pigment  when  cultivated  in  beef  gelatin.  It  liquefies  gelatin 
more  slowly  than  the  aureus  or  albus. 

The  Staphylococais  cereus  albus  et  Havus — white  and  yellow  cocci. 
These  are  two  rare  and  unimportant  forms.  The  albus  is  found  in  the 
pus  of  acute  abscesses,  and  Tils  discovered  it  in  hydrant  water.  The 
Havus  was  also  found  in  acute  abscess.  Passet,  the  discoverer,  has 
only  found  them  in  two  cases  of  abscess;  other  investigators  have  been 
unable  to  find  them.  Under  the  microscope  they  cannot  be  distin- 
guished from  the  other  varieties.  When  cultivated  in  artificial  media, 
they  each  develop  their  characteristic  pigment,  and  produce  a  dull, 
waxy  growth  when  cultivated  upon  the  surface  of  gelatin  plates. 

The  Micrococcus  pyogenes  tenuis.  This  coccus  obtained  its  name 
from  the  great  delicacy  of  it?  growth.  It  was  discovered  by  Rosen- 
bach  in  the  pus  of  an  abscess,  and  is  another  rare  form  of  pyogenic 

3 


l8  SURGERY    OF    THE    FACE,    MOUTH,    AND    TAWS. 

COCCUS.  It  is  more  than  probable  that  like  the  cereus  it  may  have  had 
only  an  accidental  presence  in  an  abscess,  and  not  be  in  any  sense  a 
pus-microbe.  Under  the  microscope  it  presents  a  somewhat  irregular 
shape,  and  is  larger  than  the  aureus.  It  produces  a  thin,  transparent, 
varnish-like  film  upon  the  agar  culture. 

The  Streptococcus  pyogenes  (Fig.  i6)  is  a  very  important  variety  of 
the  pyogenic  cocci.  It  is  usually  found  alone,  but  occasionally  it  is 
associated  with  the  staphylococci.  The  arrangement  of  the  organism 
is  in  chains  or  rows,  usually  from  six  to  ten  being  attached  together. 
They  measure  in  diameter  about  one  micro-millimeter.  Micro- 
scopically they  are  identical  with  the  streptococcus  of  erysipelas,  the 
only  discoverable  dift'erence  being  one  of  size,  the  erysipelas  organism 
being  the  larger.  The  streptococcus  grows  at  house  temperature,  but 
is  more  active  at  a  temperature  of  from  30^  to  37°  C.  On  culture- 
media  the  coccus  reaches  its  full  development  in  from  four  to  five 
days.  It  is  not  particularly  sensitive  to  the  absence  of  oxygen,  but 
nevertheless  grows  best  upon  the  surface  of  the  gelatin.  At  first  it  has 
a  transparent  whitish  appearance,  but  later  this  color  changes  to  a  faint 
brown.  It  grows  most  readily  in  bouillon,  multiplying  with  great 
rapidity.  The  organism  is  found  under  normal  conditions  in  the  saliva 
and  mucous  secretions  of  the  mouth  and  nasal  passages,  in  vaginal 
mucus,  and  in  the  urethra;  it  is  also  found  as  a  "mixed  infection" 
associated  with  the  pathogenic  organisms  of  typhoid  fever,  pneumonia, 
tuberculosis,  scarlet  fever,  and  diphtheria,  and  may  therefore  be  an 
important  agent  in  causing  the  various  complications  of  these  affec- 
tions. 

The  BacUhis  pyocyaneus  is  a  widely  distributed  form,  but  not  neces- 
sarily a  pus-producing  microbe.  It  is  the  organism  of  blue  or  green 
pus,  and  is  found  in  wounds  with  purulent  or  serous  discharges,  in  the 
perspiration,  and  in  the  viscera  of  human  cadavers.  It  is  a  small,  slen- 
der rod  with  distinctively  rounded  ends,  and  may  occur  in  chains  or 
rows,  usually  arranged  five  or  six  in  a  row.  It  has  active  motility,  and 
produces  upon  gelatin  a  beautiful  green  fluorescent  pigment.  The 
pigment  is  formed  when  the  organism  is  in  contact  with  the  oxygen, 
and  this  may  be  seen  upon  the  edges  of  dressings  and  bandages.  It 
grows  readily  at  house  temperature,  and  belongs  to  that  class  which 
will  grow  and  multiply  with  a  scant  amount  of  oxygen.  Spores  have 
not  been  seen  to  form.  The  coloring  matter  produced  by  this  organ- 
ism has  been  termed  "pyocyanine."  It  was  discovered  by  Bouchard 
that  cultures  of  the  Bacillus  pyocyaneus  will  prevent  the  development 
of  anthrax  or  splenic  fever,  if  injected  into  the  tissues  of  animals  al- 
ready infected  with  virulent  cultures  of  the  anthrax  bacillus;  and  that 
the  disease  could  be  cured  by  the  same  means  even  after  it  had  devel- 
oped. 


SURGICAL   BACTERIOLOGY. 


19 


The  Bacillus  pyogenes  fcetidus  is  a  rare  and  unimportant  organism 
found  in  ischio-rectal  abscesses.  Upon  gelatin  cultures  it  forms  upon 
the  surface  a  white  or  grayish  film  of  delicate  growth.  When  grown 
upon  agar  or  potato,  it  produces  a  light  brown  color  and  has  an  offen- 
sive odor. 

The  Micrococcus  tetragemis  is  also  a  somewhat  rare  form,  and  was 
first  found  by  Gaffky  in  a  tuberculous  cavity  of  a  lung;  it  is  also  occa- 

FlG.   16. 


^                                     «^ 

» 

'■% 

1 

m 

)     . 

•^  ^'^ ! 

A  • 

V 

1 

'  ^4  5        "^ 

^' 

> 

.  % 

^    ^. 

^ 

Streptococcus  pyogenes. 


■sionally  seen  in  both  morbid  and  healthy  expectorations.  Steinhaus 
found  it  in  an  acute  abscess  near  the  angle  of  the  jaw.  lakowski  also 
found  it  in  two  cases  of  acute  abscess,  one  of  the  finger,  the  other  in 
the  palm  of  the  hand.  This  organism  is  characterized  by  being  grouped 
in  fours  and  involved  in  a  capsule,  hence  its  name,  tetragenus.  In  cul- 
ture-media the  coccus  does  not  grow  in  any  regular  order,  .but  when 
found  in  the  tissues  it  is  always  in  groups  of  four  imbedded  in  a  gela- 
tinous envelope.     It  takes  the  stain  of  all  anilin  dyes,  and  also  of  the 


20  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

Gram  method.  It  is  an  aerobic  organism,  and  when  grown  upon 
gelatin  appears  as  thick,  globular,  whitish  masses  with  a  somewhat 
glistening  surface,  but  does  not  cause  liquefaction  of  the  gelatin. 

Steinhaus  and  others  have  proved  by  experimental  research  that 
pus  may  be  produced  without  the  aid  of  the  pus-producing  micro- 
organisms, by  the  introduction  into  the  tissues  of  certain  irritating 
chemical  substances,  but  that  the  pus  so  produced  was  aseptic,  an<l 
that  inoculation  with  it  would  not  produce  an  infectious  inflammation. 
It  was  also  found  that  injection  of  the  chemical  substances  elaborated 
by  the  pyogenic  cocci  when  separated  from  them  would  produce  pus  of 
a  non-bacterial  character.  Practically,  however,  this  knowledge  is  of 
little  value  from  the  clinical  standpoint;  as  acute  suppuration  without 
the  presence  of  the  pyogenic  micro-organisms  in  the  system  is  never 
observed.  Mechanical  irritation  or  the  presence  of  foreign  bodies  in 
the  tissues  cannot  produce  an  infectious  pus  without  the  aid  of  micro- 
organisms. The  power  of  the  pyogenic  cocci  to  produce  pus  lies  in 
their  ability  to  liquefy  the  fibrinous  elements  of  the  tissues  and  the 
mflammatory  exudates.     (Senn.) 

The  presence  of  the  pyogenic  cocci  is  exceedingly  rare  in  cold 
abscesses,  and  for  this  reason  it  has  generally  been  supposed  that  they 
were  only  produced  by  the  Bacillus  tiiber miosis,  but  Ernst  and  several 
other  observers  have  found  the  Staphylococcus  aureus  and  albus  in 
.  cases  of  psoas  abscess.  The  failure  to  obtain  cultures  of  the  pyogenic 
organisms  in  cold  abscess  may  possibly  be  due  to  the  death  of  the 
microbes  as  a  result  of  the  age  of  the  abscess.  Acute  inflammation 
often  immediately  follows  the  opening  of  such  abscesses,  either  from 
infection  from  the  outside,  or  growth  of  latent  spores  previously  depos- 
ited, and  which  have  taken  on  active  growth  and  multiplication  as  a 
result  of  the  changed  surroundings  which  have  furnished  a  favorable 
soil  for  their  development. 


CHAPTER     II. 
SURGICAL  BACTERIOLOGY  (Continued). 

The  subject  of  Surgical  Bacteriology  would  be  very  incomplete 
if  the  pyogenic  organisms  were  the  only  forms  considered  in  these 
pages.  Prominent  as  they  are  in  all  surgical  practice,  they  are  never- 
theless much  more  amenable  to  treatment  by  antiseptics,  and  far  less 
dangerous  to  the  life  of  the  patient  than  some  of  the  forms  to  be  men- 
tioned later.  The  interest  of  the  surgeon  is  largely  taken  up  with  the 
prevention  of  suppuration  following  injury  and  surgical  operations, 
but  there  are  several  diseases  due  to  the  presence  of  micro-organisms 
which  sometimes  present  very  grave  and  alarming  symptoms,  and 
which  the  surgeon  must  be  prepared  to  combat.  There  can  be  no 
better  preparation  for  such  a  battle  than  a  knowledge  of  the  character, 
number,  and  fighting  qualities  of  the  enemy,  his  base  of  supplies,  the 
strong  and  weak  points  in  his  line  of  battle,  and  the  number  of  his 
efficient  reserves.  The  science  of  bacteriology  furnishes  this  knowl- 
edge to  the  surgeon. 

The  Bacillus  coll  communis  (Fig.  17)  is  constantly  found  in  the 
discharges  of  healthy  and  unhealthy  persons.  It  was  first  found  in  the 
discharges  of  cholera  patients  at  Naples.  It  is  also  found  outside  the 
body  in  the  air,  in  water,  and  in  putrefying  fluids.  The  importance  of 
this  organism  has  recently  been  augmented  by  its  recognition  as  a 
cause  of  septic  and  suppurative  processes  in  the  peritoneal  cavity. 

This  bacillus  is  usually  seen  as  a  short  rod  with  rounded  ends ; 
it  most  frequently  forms  in  pairs,  but  it  may  be  combined  in  chains 
of  from  four  to  six  filaments.  Occasionally  both  of  these  forms  are 
associated,  which  may  lead  to  a  mistake,  as  the  appearance  is  that 
of  a  mixed  culture.  The  organism  possesses  numerous  and  peculiar 
cilia.  Spores  have  not  been  demonstrated.  It  stains  readily  with  the 
anilin  dyes,  but  is  decolorized  with  iodin.  It  grows  freely  upon  acid 
or  alkaline  media,  with  or  without  the  presence  of  oxygen ;  the  pro- 
ducts of  its  growth  are  acid,  and  it  does  not  liquefy  gelatin.  On 
gelatin  plates  it  has  two  forms  of  growth:  One  is  an  irregular  film, 
rapidly  spreading  over  the  plate,  and  having  an  opalescent  color,  while 
the  other  is  an  ivory-white,  heaped-up  colony,  which  shows  no  ten- 
dencv  to  spread.     Under  favoring  circumstances  other  bacteria  like 


22 


SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 


the  typhoid  bacilkis  and   the  pneumococcus   may   assume   pyogenic 
qualities. 

Fig.  17. 


'       /      .•       ^*      • 


Bacillus  coli  communis.     X  1200. 

The  Streptococcus  erysipelatis  (Fig.  i8)  so  closely  resembles  the 
Streptococcus  pyogenes  that  it  is  almost  impossible  to  distinguish  be- 

FiG.  18. 


Streptococcus  erysipelatis.     X  1200. 


tween  them,  the  only  physical  difference  discoverable  being  one  of  size, 
the  erysipelatis  coccus  being  the  larger.     (Rosenbach.)     The  consensus 


SURGICAL    BACTERIOLOGY, 


^Z 


of  opinion,  liowevcr.  is  in  favor  of  their  identity,  for  the  reason  that  the 
majority  of  bacteriologists  are  unable  to  detect  any  differences  which 
are  constant  between  them. 

The  description  of  this  organism  is  the  same  as  for  the  Strepto- 
coccus pyogenes.  It  is  without  doubt  the  cause  of  erysipelas,  andl 
perhaps  of  puerperal  fever,  for  there  is  a  very  close  relationship  exist- 
ing between  these  conditions,  as  many  medical  men  have  learned  by 
sad  experience.  Experimental  research  has  discovered  that  culti- 
vations of  the  streptococcus  from  puerperal  cases  injected  into  rabbits 

produced  erysipelas. 

F"iG.  19. 


GONOCOCCUS. 


The  infection  of  old  ulcers  with  the  virus  of  erysipelas  has  often 
proved  curative,  and  cases  are  on  record  in  which  tumors  have  disap- 
peared during  an  attack  of  erysipelas.  Cultures  of  the  organism  have 
been  used  frequently  of  late  in  the  treatment  of  inoperable  neoplasms, 
particularly  sarcomas,  with  varying  success. 

The  Gonococcus  (Fig.  19)  is  the  specific  micro-organism  which  pro- 
duces gonorrhea.  It  is  found  in  gonorrheal  pus,  generally  in  the  form 
of  a  diplococcus,  and  measures  1.25  micro-millimeters  in  diameter. 
It  is  exceedingly  difficult  to  cultivate,  only  growing  upon  blood-serum 
at  a  temperature  of  33°  to  37°  C,  and  not  in  company  with  other 
organisms.  One  of  its  marked  peculiarities  is  the  power  which 
it  possesses  to  enter  other  cells,  and  grow  and  multiply  within  them. 
This  peculiarity  differentiates  it  from  nearly  all  other  forms  of  micro- 
cocci. It  is  rare  to  find  a  gonococcus  outside  of  a  pus-cell.  Some- 
times the  cell  becomes  so  filled  with  them  as  to  lose  all  of  its  character- 
istics and   assume  the  appearance  of  a   cluster  of  diplococci.      The 


24 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


gonococcus  Stains  well  with  methyl  blue,  but  not  with  the  Gram 
method.  Neisser  recommends  double  staining-  with  eosin  and  methyl 
blue.  Its  growth  upon  blood-serum  produces  a  thin,  varnish-like  film 
with  irregular  but  sharply  defined  edges;  later  it  becomes  grayish 
white,  and  afterward  a  slightly  brownish  hue.  The  gonococcus  is 
only  found  associated  with  certain  mucous  membranes, — those  which 
possess  a  cylinder  epithelium,  or  one  closely  allied  to  it,  like  the  mem- 

FlG.    20. 


Bacillus. 


m 

'«^ 

• 
r 

'            --a           *                             / 

:     •     I. 

« 

^.     ' 

* 

•           -J.             #     -♦.. 

Tet.anu.s.     (Shows  Smear  of  Culture-Medium.  I  1200. 


branes  of  the  male  and  female  urethra,  vagina,  uterus,  and  conjunctiva. 
Why  it  should  grow  in  these  particular  membranes  and  only  in  their 
superficial  layers,  and  nowhere  else  in  the  body,  is  still  unexplained. 

The  Bacillus  tetani  (Fig.  20)  is  a  large  slender  rod  with  rounded 
ends, — one  end  being  enlarged,  giving  it  the  appearance  of  a  round- 
headed  pin  or  a  drum-stick.  It  is  motile,  and  belongs  to  the  anaerobic 
class  of  micro-organisms.  Exposure  to  the  air  quickly  destroys  its 
vitality.  It  sometimes  grows  in  long  chains,  the  divisions  being  im- 
perfectly seen.     The  enlargement  at  the  end  is  due  to  the  formation  of 


SURGICAL    BACTERIOLOGY. 


25 


a  spore.  The  spore  g-erminates  in  thirty  hours  if  kept  at  a  temperature 
of  Z7-S°  C.,  while  if  kept  at  the  house  temperature  it  requires  about  one 
week.  It  is  readily  colored  by  methyl  blue  and  fuchsin,  the  Gram 
method  being-  especially  adapted  to  bring  it  out  to  perfection.  It  can 
be  grown  in  cultures  of  gelatin  mixed  with  grape  sugar;  the  latter  aids 
its  rapid  development.  Being  a  strictly  anaerobic  microbe,  it  does  not 
grow  when  exposed  to  the  atmosphere,  and  this  accounts  for  the  fact 
that  the  surface  of  the  gelatin  inoculated  with  the  bacillus  remains 
sterile;  while  at  the  bottom  of  the  culture  there  is  active  growth,  send- 
ing out  innumerable  slender  prolongations,  and  producing  in  the  gela- 
tin the  appearance  of  an  inverted  fir  tree.     At  the  end  of  a  week  the 

Fig.  21. 


♦^W- 


^-^■^i; 


K.            V 

\. 

IL:       ' 

Bacillus  tuberculosis  in  Sputum.    X  1200. 


gelatin  begins  to  liquefy,  and  soon  the  whole  mass  is  changed  into  a 
hght  gray,  tenacious,  shining  substance. 

The  spores  have  been  found  in  garden  soil,  in  masonry,  in  the  dust 
of  the  streets,  in  decomposing  liquids,  and  in  stable  manure.  Hence 
the  frequency  of  tetanus  among  gardeners  and  stable  men.  Tetanus 
is  thought  to  be  produced  by  the  elaboration  of  certain  toxic  sub- 
stances from  the  bacillus  which  are  taken  up  by  the  circulation,  and 
cause  irritation  of  the  nerve-centers.  Brieger  obtained  three  toxic 
substances  from  cultures  of  the  bacillus,  which  he  named  "tetanin," 
''tetanotoxin,"  and  "spasmotoxin."  All  of  these,  wdien  injected  into 
animals,  caused  spasms  or  convulsive  movements,  and  finally  paralysis. 

The  Bacillus  tuber  ado  sis  (Fig.  21)  is  a  small,  slender  rod,  varying  in 
length  from  one-fourth  to  three-fourths  the  diameter  of  a  red  blood- 
corpuscle.     It  has  rounded  ends,  and  is  somewhat  bent  or  curved  near 


26  SURGERY    OF    THE    FACE,    MOUTH,    AXD    JAWS. 

the  center;  is  usually  single,  sometimes  arranged  in  pairs,  and  often  in 
the  form  of  the  letter  V,  or  strung-  together.  The  longest  rods  are 
usually  seen  in  the  sputa  of  phthisical  patients.  This  bacillus  does  not 
possess  motile  power.  It  is  thought  by  Baumgarten  that  it  multiplies 
by  endogenous  spore  formation,  from  the  fact  that  the  cheesy  material 
of  a  tubercle  in  which  no  bacilli  can  be  discovered  by  any  method  of 
staining,  if  injected  into  animals,  produces  the  disease.  The  bacilli  have 
never  been  seen  in  the  process  of  spore  formation,  and  free  spores  have 
never  been  discovered.  These  bacilli  are  very  tenacious  of  life;  sputum 
charged  with  them  may  be  kept  for  months  and  even  years  in  a  dried 
state  without  endangering  their  vitality.  They  also  possess  great 
resistive  power  to  the  acids  of  the  stomach  and  to  the  products  of 
decomposition;  they  may  even  pass  through  the  entire  alimentary  tract 
without  in  any  way  impairing  their  vitality.  This  resistance  is  due  to- 
the  unusually  tough  enveloping  membrane  or  cell-wall  possessed  by 
the  bacillus.  It  requires  the  boiling  temperature  for  twenty  minutes 
to  destroy  the  organisms  in  tuberculous  sputa.  The  tubercle  bacillus 
is  a  facultative  anaerobic  microbe, — grows  with  or  without  oxygen,  but 
flourishes  best  in  the  atmosphere.  It  is  among  the  most  difBcult  of  tlie 
bacteria  to  stain  with  the  anilin  dyes,  and  like  the  bacillus  of  leprosy^ 
which  it  greatly  resembles,  does  not  readily  yield  to  the  action  of 
bleaching  agents.  Nearly  all  other  bacterial  forms  are  readily  decolor- 
ized. The  bacilli  are  found  in  the  tubercles,  between  the  leucocytes  in 
the  epithelioid  cells,  and  in  the  giant  cells. 

This  organism  is  exceedingly  difficult  to  cultivate,  though  it  grows 
upon  the  hardened  blood-serum  of  Koch,  or  upon  a  combination  of 
agar  and  glycerol,  but  it  requires  from  twenty-one  to  twenty-eight 
days  when  hardened  blood-serum  is  used,  which  indicates  a  predilec- 
tion of  the  bacillus  for  glycerol.  At  the  end  of  this  time  the  culture 
appears  as  thick,  dull,  grayish-white  scales,  very  dry  and  brittle. 
Material  for  cultures  is  obtained  by  inoculating  guinea-pigs  with 
tuberculous  sputa.  When  the  disease  is  established  the  animal  is 
killed,  and  fragments  of  tubercle  from  the  lungs  are  placed  upon  the 
culture-medium. 

TTie  tubercle  bacilli  are  never  found  growing  outside  of  the  living 
tissues  of  man  and  animals,  as  the  proper  conditions  of  nutrition  and 
temperature  can  nowhere  else  be  found;  they  are  therefore  true  animal 
parasites.  Inoculation  may  occur  through  abrasions  of  the  skin, 
through  the  mucous  membrane  of  the  respiratory  tract  or  digestive 
system.  Ernst  has  shown  that  six  drops  of  milk  from  a  tuberculous 
cow  injected  under  the  skin  of  a  guinea-pig  may  develop  tuberculosis. 

The  Bacillus  mallei,  Figs.  22,  23  (bacillus  of  glanders),  is  a  short, 
straight  rod;  in  length  about  two-thirds  the  diameter  of  a  red  blood- 
corpuscle, — that  is,   somewhat   shorter  and  a  trifle  thicker  than  the 


SURGICAL    BACTERIOLOGY. 


27 


tubercle  bacillus.     They  are  generally  found  single,  but  are  sometimes 
arranged  in  couples,  side  by  side.     In  the  tissues  they  are  grouped  in 


Fig.  22. 


Bacillus  mallei  (Glanders).     X  1200. 

Fig.  23. 


Bacillus  mallei  (Glanders).     X  1000. 


clusters,  either  parallel  with  one  another  or  at  various  angles.  In 
culture-media  several  of  them  may  be  joined  together  in  chains. 
They  are  non-motile,  and  belong  to  the  facultative  anaerobic  organ- 


28  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

isms.  This  bacillus  was  discovered  by  Loffler  and  Schiitz,  who  suc- 
ceeded in  demonstrating  its  presence  in  the  tissues,  cultivated  it  outside 
the  living  organism,  and  produced  the  disease  by  inoculation  of  ani- 
mals with  the  culture.  The  animals  in  which  the  virus  can  be  readily 
inoculated  are  the  horse,  the  ass,  goats,  cats,  field  mice,  and  guinea- 
pigs.  Lions  and  tigers  have  also  been  successfully  inoculated  with  it. 
Pigs,  white  mice,  house  mice,  and  oxen  are  not  susceptible  to  the  dis- 
ease. Man  frequently  becomes  inoculated  through  abrasions  upon  the 
hands,  etc.  Post-mortem  examinations  reveal  nodules  in  the  spleen, 
liver,  and  lungs  which  in  many  respects  resemble  the  tubercle  nodule. 
The  bacilli  are  found  most  plentifully  in  the  center  of  the  nodule,  and 
generally  lying  between  the  cells.  Epithelioid  cells  and  leucocytes 
make  up  the  bulk  of  the  nodule;  giant  cells  are  never  present.  The 
secretions  from  the  nasal  passages  have  few  bacilli  in  them. 

The  organism  is  readily  stained  and  as  readily  decolorized.  It 
grows  readily  upon  a  4  per  cent,  glycerol-agar,  and  upon  potato.  The 
potato  culture  produces  around  the  border  a  yellowish-green  color, 
which  would  seem  to  be  pathognomonic,  as  no  other  organism  gives 
this  color  under  cultivation.     It  grows  best  at  a  temperature  of  37°  C. 

The  Bacillus  of  Malignant  Edema  is  a  saprophytic  organism.  It  is 
a  slender  rod,  narrower  than  the  anthrax  bacillus,  for  which  it  is  some- 
times mistaken ;  frequently  arranged  in  bands,  which  are  often  bent  or 
curved.  They  are  strictly  anaerobic,  and  are  endowed  with  active 
motility.  Motion  soon  ceases  on  their  coming  in  contact  with  oxygen, 
as  they  are  exceedingly  sensitive  to  even  the  slightest  trace  of  it. 
Spores  are  formed  in  a  temperature  above  20°  C;  these  are 
large,  and  may  be  situated  at  the  center  or  the  end  of  the  rod.  They 
stain  well  with  the  anilin  dyes,  but  not  by  the  Gram  method.  When 
stained  the  ends  of  the  rods  appear  pointed,  which  distinguishes  them 
from  the  anthrax  bacillus.  They  grow  best  in  gelatin  cultures  to  which 
from  I  to  2  per  cent,  of  grape-sugar  has  been  added.  They  liquefy 
gelatin,  and  usually  form  gas  which  distends  the  needle  tract  and  gives 
off  an  offensive  odor  peculiar  to  putrefaction. 

The  bacillus  is  found  in  decomposing  substances,  in  dirty  water, 
in  the  dust  of  the  streets,  and  in  rich  garden-mold;  being  found  in 
greatest  abundance  in  the  latter.  Injections  of  garden  soil  are  more 
virulent  than  the  pure  culture  of  the  bacillus,  and  when  introduced 
subcutaneously  in  the  guinea-pig,  produce  a  progressive  emphysem- 
atous gangrene  similar  to  that  seen  in  man.  The  organism  is  occasion- 
ally found  in  cases  of  traumatic  gangrene  in  man,  but  always  in  the 
superficial  tissues  and  never  in  the  blood-vessels,  in  marked  contrast  to 
the  habit  of  the  anthrax  bacillus.  According  to  Chauveau,  animals 
which  have  recovered  from  an  attack  of  malignant  edema  are  rendered 
immune  to  the  disease  ever  afterward. 


SURGICAL    BACTERIOLOGY. 


29 


The  " psaido-cdcma"  bacillus  is  distinguished  from  the  bacillus  of 
malignant  edema  by  its  thicker  form,  the  possession  of  a  very  bright 
border,  and  by  the  formation  of  two  spores  in  each  rod.  It  is  strictly 
an  aerobic  organism,  and  not  so  infectious  as  the  true  bacillus.  In 
cultures  it  is  accompanied  by  an  abundant  gas-formation  which  has  the 
odor  of  old  cheese.  It  is  sometimes  found  in  traumatic  gangrene  of 
man.  Noma,  a  malignant  gangrenous  inflammation  of  the  mouth  and 
genitals  in  young  children,  is  probably  caused  in  many  cases  by  the 
bacteria  of  this  class,  which  with  the  p3-ogenic  cocci  are  always  present 
and  ready  to  attack  wounds  located  in  uncleanly  parts  of  the  body,  and 
in  the  tissues  whose  vitality  has  been  impaired  or  destroyed  by  injury. 

Fig.  24. 


4.^1- 


Bacillus  of  Leprosy.    X  1000. 


The  Bacillus  of  Leprosy.  This  bacillus — the  discovery  of  which 
is  shared  by  Hansen  and  Xeisser — in  appearance  is  almost  identical 
with  the  tubercle  bacillus  and  the  glanders  bacillus.  It  is  a  long, 
slender  rod,  with  sharpened  ends,  is  non-motile,  and  is  the  only 
organism  which  reacts  to  the  coloring  reagents  in  the  same  manner  as 
the  tubercle  bacilli.  (Fig.  24.)  The  readiness  with  which  it  takes  the 
anilin  dves,  and  also  stains  by  the  Gram  method,  distinguishes  it  from 
the  tubercle  bacilli. 

Bacteriologists  have  not  as  yet  settled  the  question  as  to  its  being 
the  actual  cause  of  leprosy.  The  bacilli  of  leprosy  are  usually  found  in 
the  skin  and  the  tissues  immediately  surrounding  the  nerves;  in  the 
lymphatic  glands,  the  spleen  and  liver,  but  rarely  in  the  blood.     They 


30  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

grow  in  clusters,  usually  inside  of  the  cells — leucocytes  and  epithelioid 
cells,  which  in  consequence  have  been  called  lepra  cells. 

Babes  of  Bucharest  stated  in  a  paper  read  before  the  International 
Leprosy  Congress  (1897)  upon  the  bacteriology  of  Leprosy,  that  the 
Hansen-Neisser  bacilli  were  found  in  great  numbers  in  the  mucous 
secretions,  and  that  this  was  the  chief  means  of  conveying  infection. 
In  the  discussion  which  followed  it  was  the  unanimous  opinion  of  the 
Congress  that  the  Hansen-Neisser  bacillus  was  the  specific  pathogenic 
micro-organism  of  the  disease,  and  that  it  finds  in  man  alone  of  all 
animals  a  suitable  soil  for  its  growth.  It  was  also  stated  as  the  opinion 
of  the  Congress  that  although  leprosy  was  contagious  it  was  not  heredi- 
tary. 

The  Bacillus  of  Syphilis.  The  microbic  origin  of  syphilis  has  at- 
tracted the  attention  of  bacteriologists  generally,  but  so  far  the  specific 
organism  of  the  affection  has  not  been  conceded.  The  clinical  features 
of  the  disease  make  its  microbic  origin  almost  certain,  and  that  the 
organism  is  a  bacillus,  but  it  has  not  been  satisfactorily  demonstrated. 
Lustgarten  announced  in  1884  the  discovery  of  an  S-shaped  bacillus 
in  the  tissues  and  discharges  of  syphilitic  ulcers  which  closely  resem- 
bled the  tubercle  bacillus,  but  he  was  unable  to  successfully  cultivate 
it.  It  was  distinguishable  from  other  forms  by  the  peculiar  methods 
necessary  to  stain  it.  Gelatin  made  from  the  bladders  of  Russian  stur- 
geon is  said  to  be  a  medium  upon  which  it  may  be  successfully  culti- 
vated. Doubt  has  been  thrown  upon  Lustgarten's  discovery  through 
the  simultaneous  finding  by  two  different  observers  of  a  similar  bacillus 
in  the  preputial  and  vulvar  smegma.  Eve  and  Lingard  cultivated  a 
bacillus  which  they  found  in  the  blood  and  tissues  of  syphilitic  patients, 
and  describe  it  as  resembling  the  tubercle  bacillus.  It  w^as  readily 
stained  by  the  ordinary  anilin  dyes  and  by  the  Gram  method,  but 
would  not  take  the  stain  by  Lustgarten's  method.  Pure  cultures  were 
obtained,  but  inoculation  of  monkeys  with  these  gave  negative  results. 
Disse  and  Taguchi  found  an  almost  constant  "coccus"  in  patients  suf- 
fering from  secondary  syphilis.  The  organism  was  found  isolated  or  in 
groups  between  the  corpuscles.  Inoculation  with  pure  cultures,  in  rab- 
bits, dogs,  and  sheep,  produced  a  chronic  infectious  disease,  which  was 
transmitted  to  the  offspring. 

Martineau  and  Hammic  succeeded  in  producing  eruptions  in  mon- 
keys resembling  those  of  syphilis,  and  nodules  whicli  simulated  indu- 
rated chancre,  by  inoculating  these  animals  with  a  culture  bouillon  in 
which  fragments  of  chancres  had  been  placed,  and  in  which  the  growth 
of  bacilli  had  been  demonstrated.  Secondary  symptoms  were  also 
developed.  Klebs  successfully  inoculated  monkeys  in  the  same  man- 
ner. Mucous  patches  were  developed  upon  the  buccal  mucous  mem- 
brane, and  caseous  deposits  were  found  in  the  dura  mater  which  resem- 


SURGICAL    BACTERIOLOGY,  3I 

bled  gummata.  Implantation  of  a  fragment  of  chancre  under  the  skin 
resulted  in  caseous  deposits,  resembling  the  deposits  of  tubercle.  The 
evidence  seems  therefore  to  favor  Lustgarten's  bacillus  as  the  specific 
cause  of  the  disease. 

The  Bacillus  Anthracis  is  the  organism  which  produces  anthrax,  or 
splenic  fever  in  animals.  It  is  classed  among  the  surgical  bacteria,  be- 
cause inoculation  with  the  virus  in  man  produces  malignant  pustule, 
and  this  frequently  happens  to  those  who  have  to  deal  with  animals 
sufifering  from  the  malady,  or  who  handle  the  hides  or  wool  of  such 
animals;  hence  the  name  "wool-sorters'  disease."  It  also  deserves  to 
be  so  classed  on  account  of  its  position  historically,  for  it  was  the  first  of 
the  bacterial  forms  discovered  in  the  blood  and  tissues,  and  the  first  to 

Fig.  25. 


I A  A   • 


Bacillus  of  Anthrax.     X  1200. 

be  demonstrated,  experimentally,  as  the  specific  cause  of  a  disease. 
Upon  the  investigations  which  proved  this  microbe  to  be  the  real  and 
only  cause  of  splenic  fever,  the  whole  science  of  pathogenic  bacteriology 
has  since  been  reared. 

The  bacillus  of  anthrax  (Fig.  25)  is  a  large  rod,  from  three  to  six 
micro-millimeters  in  length,  and  1.5  micro-millimeters  in  thickness. 
When  grown  upon  culture-media  they  appear  as  bright,  transparent 
rods,  with  slightly  rounded  ends,  and  are  entirely  devoid  of  motion. 
The  bacilli  taken  from  the  blood  of  animals  which  have  recently  died  of 
anthrax  appear  somewhat  larger  at  each  end  than  in  the  center,  and  are 
joined  together  in  the  form  of  a  chain,  simulating  the  articulation  of  the 
phalangeal  bones.    This  form  of  enlarged  ends  and  articulation  of  tlie 


;^2  SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 

rods  is  peculiar  to  the  anthrax  bacilkis,  and  dififerentiates  it  from  all 
other  forms  of  bacteria.  The  spores  when  forming  are  seen  as  bright, 
glistening  spots  in  the  center  of  the  bacilli.  The  developed  organisms 
are  rather  delicate,  but  the  spores  are  among  the  most  resistant  to  ex- 
ternal influences,  and  are  therefore  commonly  used  as  a  test  of  the 
value  of  germicides.  The  bacilli  can  be  cultivated  in  bouillon,  agar, 
gelatin,  or  potato,  and  in  human  urine  freely  exposed  to  the  air. 
Oxygen  is  necessary  to  their  growth,  and  they  grow  best  at  a  tempera- 
ture of  37°  C.  They  will  not  grow  at  a  lower  temperature  than 
i6°  C,  or  at  a  higher  temperature  than  45°  C. ;  the  spores  will  not 
germinate  without  a  large  supply  of  oxygen  or  below  a  temperature 
of  24°  C.  Pasteur  succeeded  in  producing  an  attenuated  virus  by 
long  cultivation  or  cultivation  carried  on  at  high  temperature,  which 
by  repeated  injections  rendered  animals  immune  to  the  disease  for  a 
certain  time — about  a  year — through  all  avenues  of  infection  except 
the  intestinal  canal.  The  spores  are  taken  into  the  stomach  with  food 
that  has  been  contaminated  by  other  diseased  cattle,  from  nasal  dis- 
charges, urine,  and  feces. 

Oxen  and  sheep  are  particularly  susceptible  to  infection  through 
the  alimentary  mucous  membrane,  and  as  this  is  the  most  common 
avenue  of  infection  in  cattle,  further  experiment  will  be  necessary  to 
determine  the  possibility  of  devising  a  practical  method  of  protection 
from  the  disease  by  "vaccination." 

Actinomyces  is  a  ray-bacterium  or  a  ray-fungus,  which  produces  a 
disease  in  cattle,  pigs,  etc.,  known  as  Actinomycosis,  or  lumi)v-iaw 
(Fig.  26).  This  bacterium  is  classed  with  the  surgical  bacter  • 
the  disease  occasionally  occurs  in  man  as  a  result  of  infection.  The 
organism  occurs  in  the  form  of  spirally  curved  branching  threads, 
radiating  from  a  common  center,  and  terminating  in  bulbed  extremi- 
ties. These  prolongations  are  so  arranged  as  to  look  something  like  a 
sunflower.  .The  bacterium  macroscopically  appears  about  the  size  of 
a  millet-seed,  yellowish  in  color,  and  of  a  tallowy  consistence.  It  can 
be  cultivated  upon  blood-serum,  agar,  or  gelatin,  and  the  temperatures 
in  which  its  growth  is  most  active  are  from  33°  to  37°  C.  Development 
is  completed  in  from  five  to  six  days.     (Fig.  27.) 

Actinomycosis  in  man  is  not  a  very  common  affection,  but  one 
that  can  be  diagnosed  with  great  readiness  on  account  of  the  peculiar 
character  of  the  micro-organism. 

Patliogenic  Mouth-bacteria. — To  Prof.  Miller,  of  the  University  of 
Berlin,  science  is  indebted,  more  than  to  any  other  investigator  in  the 
realm  of  bacteriology,  for  our  knowledge  of  the  mouth-bacteria.  This 
author  has  shown,  in  his  work  upon  the  "Micro-organisms  of  the 
Human  Mouth,"  that  nearly  all  of  the  pathogenic  and  many  of  the  non- 
pathogenic micro-organisms  have  been  found  in  the  human  mouth ; 


SURGICAL    BACTERIOLOGY. 
Fig.  26. 


33 


The  Ray-Fungus.     (Actinomyces.)     (After  Ponfick.) 
Fig.  27. 


ACTINO.MYCOSIS  (RaV-FUNGUS)  OF  SUBMAXILLARY  GlanD  OF  A   SteER.      X  50O. 

■1 


34  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

thus  establishing  the  fact  that  this  cavity  is  often  the  avenue  through 
which  infections  of  a  considerable  number  of  serious  and  sometimes 
fatal  diseases  may  gain  access  to  the  system. 

Among  the  more  important  forms  of  pathogenic  micro-organisms 
found  in  the  oral  cavity  may  be  mentioned  the  micrococcus  of  sputum 
septicemia,  Bacillus  crassus  sputigenus,  Staphylococcus  aureus  and 
albus,  Streptococcus  pyogenes,  Micrococcus  tetragenus,  the  pneumo- 
coccus,  and  many  others.  Biondi  isolated  from  the  human  saliva  five 
different  forms  of  pathogenic  micro-organisms  to  which  he  gave  the 
following  names :  Bacillus  salivarius  septicus,  Coccus  salivarius 
septicus.  Micrococcus  tetragenus,  Streptococcus  septo-pycemicus,  and 
Staphylococcus  salivarius  pyogenes. 

Cultures  of  all  these  forms  were  found  to  be  more  or  less  virulent 
when  injected  subcutaneously  into  mice  and  guinea-pigs. 

Miller  found  a  considerable  number  of  other  bacterial  forms  pos- 
sessing pathogenic  action,  four  of  which  he  examined  in  more  elaborate 
detail,  and  named  as  follows :  Micrococcus  gingivce  pyogenes,  Bacte- 
rium gingivcB  pyogenes.  Bacillus  dentalis  viridans,  and  Bacillus  pulpce 
pyogenes. 

The  first  two  were  found  in  the  pus  from  pyorrhea  alveolaris,  the 
third  was  found  in  decaying  dentine,  and  the  last  in  gangrenous  pulps. 
Cultures  made  from  the  first  two  and  the  last  were  found  to  be  de- 
cidedly virulent,  causing  death  in  from  ten  to  twenty-five  hours  when 
injected  into  the  abdominal  cavity  of  white  mice.  Bacillus  dentalis 
viridans,  when  injected  into  the  abdominal  cavity  of  white  mice  and 
guinea-pigs,  produced  death  from  peritonitis  in  from  twenty-two  hours 
to  six  days. 

Black,  in  his  investigations,  found  that  the  pus-producing  bacteria 
were  almost  constant  in  the  human  mouth,  and  says :  "We  must  take 
into  consideration  the  fact  that  the  pyogenic  bacteria  are  generally 
present  in  the  oral  cavity,  and  endanger  every  wound  that  we  make  in 
it." 

Miller,  in  giving  emphasis  to  the  fact  that  the  mouth, — loaded  as 
it  is  with  so  many  forms  of  pathogenic  micro-organisms — is  a  most 
prolific  source  of  infection,  says :  "The  diseases  caused  by  the  patho- 
genic bacteria  of  the  mouth  may  be  considered  under  six  heads,  accord- 
ing to  the  point  of  entrance  of  the  infection : 

"i.  Infections  caused  by  a  breach  in  the  continuity  of  the  mucous 
membrane,  brought  about  by  mechanical  injuries  (wounds,  extrac- 
tions, etc.).    These  lead  either  to  local  or  to  general  disturbances. 

"2.  Infections  through  the  medium  of  gangrenous  tooth-pulps. 
These  usually  lead  to  the  formation  of  abscesses  at  the  point  of  in- 
fection (abscessus  apicalis),  but  also  sometimes  to  secondary  septicemia 
and  pyemia  with  fatal  terminations. 


SURGICAL    BACTERIOLOGY.  35 

"3.  Disturbances  conditioned  by  the  resorption  of  poisonous  waste 
products  formed  by  bacteria. 

''4.  Pulmonary  diseases  caused  by  the  inspiration  of  particles  of 
mucus,  small  pieces  of  salivary  calculus,  etc.,  containing  bacteria. 

"5.  Excessive  fermentative  processes  and  other  complaints  of  the 
digestive  tract,  caused  by  the  continual  swallowing  of  microbes  and 
their  poisonous  products. 

"6.  Infections  of  the  intact  soft  tissue  of  the  oral  and  pharyngeal 
cavities,  whose  power  of  resistance  has  been  impaired  by  debilitating 
diseases,  mechanical  irritants,  etc. 

"In  this  connection  the  possibility  of  an  infection  by  the  accumula- 
tion of  the  excitants  of  diphtheria,  typhus,  syphilis,  etc.,  in  the  mouth 
must  also  be  taken  into  consideration." 

Action  of  Bacteria. — The  question  of  hozv  bacteria  act  upon  the 
living  tissues  of  the  body  is  not  yet  fully  decided.  Some  observers  are  of 
the  opinion  that  the  symptoms  of  infectious  disease  are  the  result  of  the 
formation  by  the  bacteria  of  chemical  substances  of  an  irritating  or 
poisonous  nature,  a  sort  of  specific  excreta.  Others  suppose  the  phe- 
nomena, both  local  and  constitutional,  to  be  due  to  changes  brought 
about  in  the  tissues  by  the  organisms  themselves,  during  their  develop- 
ment, and  that  it  is  not  necessary  to  assume  the  formation  of  a  specific 
poison  or  virus. 

The  action  of  the  pyogenic  bacteria  locally  is  to  produce  irritation 
or  inflammation;  while  the  chemical  substances  elaborated  are  dissem- 
inated throughout  the  body,  which  by  virtue  of  a  peculiar  action — 
thought  to  be  ferment-like — augments  tissue-metamorphosis,  stimu- 
lates the  "thermic  centers,"  and  thereby  increases  the  body  tempera- 
ture, producing  fever  or  systemic  disturbance.  This  condition  is 
"known  as  septic  infection. 

The  absorption  of  ptomaines  without  the  presence  of  pathogenic 
bacteria  will  produce  grave  systemic  disturbances.  This  condition 
would  be  termed  septic  intoxication,  or  toxic  infection. 

Ptomaines,  which  are  powerful  animal  poisons,  are  developed  by 
the  process  of  decomposition  of  animal  tissue  in  the  presence  of  sapro- 
phytic bacteria.  In  their  physiologic  action  they  resemble  the  alka- 
loids, and  when  received  into  the  circulation  by  the  process  of  absorp- 
tion, they  produce  more  or  less  severe  constitutional  symptoms.  The 
"toxines"  probably  belong  to  this  class  of  substances.  The  develop- 
ment of  these  substances — ptomaines — appears  to  exert  a  controlling 
or  inhibitory  effect  upon  the  micro-organisms.  Many  of  the  artificial 
■cultures  of  the  bacteria,  after  a  period  of  growth,  cease  to  develop,  and 
it  is  by  virtue  of  the  formation  of  these  substances  that  this  controlling 
•effect  is  brought  about. 

Leucomaines  are  animal  alkaloids,  which  are  produced  in  the  tis- 


36  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

sues  by  metabolism  (tissue  changes),  independent  of  micro-organisms. 
Their  pathologic  significance  is  as  yet  not  well  defined. 

The  effect  of  the  virus  of  certain  bacteria  upon  the  vital  fluids  and 
the  tissues  of  the  body  in  certain  diseases  is  to  give  protection  against 
future  attacks, — in  other  words,  to  render  the  organism  immune. 

Pasteur  thought  this  protection  or  immunity  to  be  due  to  the  ex- 
haustion of  the  chemical  substances  (supposedly)  necessary  to  main- 
tain the  life  and  development  of  the  specific  bacteria.  Fraenkel  was  of 
the  opinion  that  the  first  invasion  of  the  bacteria  left  behind  certain 
substances  which  were  inimical  to  the  further  development  of  the  same 
species  of  micro-organism,  which  might  at  some  other  time  gain  an 
entrance  to  the  system. 

The  direct  transmission  of  bacterial  diseases  from  parents  to  fetus 
is  a  question  which  has  not  yet  been  satisfactorily  proved,  and  is  hardly 
susceptible  of  a  ready  demonstration,  though  the  best  authorities  have 
admitted  for  a  long  time,  from  clinical  proofs,  that  many  infectious  sur- 
gical diseases  are  hereditary.  The  avenues  through  which  hereditary 
diseases  may  be  communicated  are  the  semen,  and  the  placenta  during 
intra-uterine  life.  It  is  well  known  that  syphilis  may  be  transmitted 
both  through  the  semen  and  the  placenta;  although  the  bacteriologic 
proofs  are  lacking  as  to  the  existence  of  a  specific  syphilis  bacillus. 
Infection  through  the  placenta  has  been  frequently  observed  in  ani- 
mals; "glanders  has  been  transmitted  from  mare  to  foal,  and  the  bacilli 
cf  anthrax,  glanders,  and  malignant  edema  have  been  shown  by 
experiment  to  pass  through  the  placenta  to  the  fetus."  (American 
Text-Book  of  Surgery.) 

The  best  of  clinical  evidence  exists  that  diseases  like  smallpox, 
typhoid  fever,  intermittent  fever,  erysipelas,  measles,  and  scarlatina  are 
directly  transmissible  from  mother  to  fetus.  Several  well-authenticated 
cases  are  on  record  in  which  these  diseases  occurred  in  newborn  chil- 
dren, and  the  lack  of  an  incubation  period  for  the  disease  can  only  be 
explained  upon  the  hypothesis  of  pre-natal  infection. 

The  tubercle  bacillus  has  been  found  in  the  testicles  and  in  the 
prostate  gland,  and  "it  requires  no  stretch  of  the  imagination  to  un- 
derstand how  the  spermatozoon  in  the  testicle  or  on  its  way  to  the 
vesiculse  seminalis  can  be  contaminated  with  bacilli  and  the  disease 
thus  transmitted  from  father  to  fetus."    (Senn.) 

The  Fallopian  tubes  are  often  the  seat  of  tuberculous  disease, 
which  makes  it  more  than  probable  that  the  ovum  in  its  passage  to  the 
uterus  may  become  infected  with  the  bacillus. 

The  General  Principles  of  Antiseptic  Treatment. — Inasmuch  as 
all  suppurative  processes  are  the  result  of  the  action  of  micro-organ- 
isms, which  enter  the  system  through  some  break  in  the  continuity  of 
the  surface,  and  cause  putrefaction  of  the  tissues  and  exudates,  the  first 


SURGICAL    BACTERIOLOGY.  37 

duty  of  the  surgeon  or  dentist  is  to  prevent  putrefaction,  and  if  it  has 
already  been  estabHshed,  to  arrest  its  further  progress. 

This  may  be  accompHshed:  First,  By  excluding  all  organisms  from 
the  zvound,  by  strict  attention  to  the  details  of  surgical  cleanliness; 
Second,  By  removing  the  organisms  zvJiich  may  already  have  gained  an 
entrance  to  the  zvonnd,  by  thorough  irrigation  before  they  can  produce 
their  harmful  effects;  Third,  By  destroying  the  organisms  which  may 
remain,  with  solutions  of  bichlorid  of  mercury,  or  other  germicides; 
Fourth,  By  removing  dead  and  dying  tissue,  and  establishing  -free  drain- 
age, for  the  escape  of  the  discharges.  Disorganized  tissue  is  the  soil 
in  which  micro-organisms  best  grow  and  flourish;  Fifth,  By  preventing 
the  formation  of  a  favorable  soil  in  zvhich  they  can  grow.  This  can  best 
be  accomplished  by  avoiding  unnecessary  manipulation  of  the  wound, 
guarding  against  tension  from  stitches  or  bandages,  and  by  careful, 
dry  antiseptic  dressings. 

Dry  dressings  are  not  applicable  in  wounds  within  the  mouth, 
vagina,  or  anus.  In  these  cases  dependence  must  be  placed  upon  free 
irrigation,  with  antiseptic  solutions. 

A  wound  is  called  aseptic  when  it  is  free  from  pathogenic  or  septic 
micro-organisms,  and  septic  when  it  is  the  seat  of  infection. 

The  term  Antiseptic  means  germ-destroying.  Asepsis  can  only 
be  secured  by  antisepsis.  An  aseptic  wound  is  therefore  one  which  is 
free  from  germs,  or  has  been  rendered  germ-free  by  antiseptic  treat- 
ment. 

An  antiseptic  dressing  is  one  which  has  been  rendered  sterile,  and 
contains  germ-destroying  substances. 

An  aseptic  dressing  is  one  which  has  been  made  germ-free  by 
sterilizing  with  heat. 

The  common  antiseptic  solutions  are  carbolic  acid,  3  to  5  per  cent. ; 
bichlorid  of  mercury,  i  part  to  5000,  or  i  to  2000,  i  to  1000,  i  to  500 
of  water;  a  saturated  solution  of  boric  acid;  Thiersch's  solution — 12 
parts  boric  acid,  4  parts  salicylic  acid,  to  1000  of  water.  Listerine 
and  borolyptol  are  also  valuable  antiseptics,  especially  for  use  in  the 
mouth,  but  are  too  expensive  for  common  use. 

Pulverized  boric  acid  and  iodoform  are  the  remedies  generally 
used  in  dry  dressing  of  wounds.  On  account  of  the  disagreeable  odor 
of  iodoform,  boric  acid  has  the  preference  with  many  surgeons.  Vari- 
ous other  antiseptics  might  be  mentioned,  but  these  are  the  ones  in 
most  common  use. 


CHAPTER  III. 
INFLAMMATION. 

A  KNOWLEDGE  of  surgical  pathology  presupposes  an  under- 
standing of  the  process  of  inflammation;  in  fact,  a  correct  appreciation 
of  tlie  various  phenomena  of  inflammation  is  absolutely  essential  as  a 
foundation  upon  which  to  build  a  correct  knowledge  of  surgical  pathol- 
ogy. It  is  therefore  of  the  utmost  importance  that  the  student  make 
himself  thoroughly  familiar  with  the  entire  subject  of  inflammation,  for 
upon  this  knowledge,  and  the  ability  to  apply  it,  will  depend  in  very 
large  measure  the  success  or  failure  of  the  practitioner  in  any  depart- 
ment of  surgery. 

To  Cohnheim  belongs  the  honor  of  first  placing  before  the  world 
a  scientific  explanation  of  the  phenomena  of  inflammation,  by  the  pub- 
lication in  1867  of  the  results  of  his  study  and  experiments  upon  the 
circulation  of  the  blood  and  the  action  of  the  white  blood-corpuscles,  as 
observed  in  inflammation.  These  labors  added  very  greatly  to  the 
then  existing  knowledge  of  the  inflammatory  process  in  the  tissues,  and 
have  since  formed  the  basis  for  all  further  research  in  this  direction. 
Cohnheim's  views,  however,  have  not  been  adopted  in  their  entirety, 
as  various  modifications  have  been  suggested  by  other  investigators, 
but  in  the  main  they  form  the  prevailing  theory  of  to-day. 

Inflammation. — Synonym,  Lat.  inUammatio  (from  inflammare, 
to  inflame. — Inflammo,  I  set  on  fire). 

Definition. — Inflammation  is  a  condition  of  nutritive  disturbance, 
characterized  by  hyperemia,  with  proliferation  of  the  cells  of  a  tissue 
or  organ,  and  attended  by  one  or  more  of  the  symptoms  of  pain,  heat, 
swelling,  discoloration,  and  disordered  function. 

Inflammation  is  a  series  of  changes  in  a  part,  identical  with  those 
which  are  produced  in  the  same  part  by  injury  from  a  chemical  or 
physical  irritant. 

Physical  Signs. — The  physical  signs  or  cardinal  symptoms  of  in- 
flammation, as  described  by  Celsus,  are  four  in  number,  viz:  Rubor, 
Tumor,  Calor,  and  Dolor, — redness,  swelling,  heat,  pain;  a  fifth  symp- 
tom has  since  been  added,  viz :  Functio  Lcesa,  disturbance  of  function 
in  the  part. 

Causes. — All  forms  of  inflammation  are  the  result  of  the  action  of 

38 


INFLAMMATION.  39 

certain  irritants.  Irritants  are  classed  under  the  four  following  heads: 
mechanical,  chemical,  septic,  and  nervous. 

A  mechanical  irritant  produces  irritation  through  its  mechanical 
action.  Examples:  Foreign  bodies,  scarification,  puncture,  acupres- 
sure, etc. 

A  chemical  irritant  is  a  substance  which  irritates  by  virtue  of  its 
chemical  reaction  upon  the  tissue  elements  to  which  it  is  applied.  Ex- 
amples: Alkalies,  acids,  croton  oil,  cantharides.  Other  examples  are 
found  in  drugs  which  have  a  predilection  for  certain  organs,  and  which,, 
if  administered  in  poisonous  doses,  will  cause  inflammation.  Mercury 
acting  upon  the  tissues  of  the  mouth  and  salivary  glands,  produces 
stomatitis,  and  salivation.  Cantharides  will  cause  irritation  of  the 
urinary  organs,  ergot  of  the  uterus,  and  uric  acid  will  cause  gouty 
inflammations.  The  toxic  inflammation  caused  by  the  poison  of 
serpents  and  insects,  the  poisonous  action  of  certain  plants,  like  the 
Rhus  toxicodendron,  and  the  ptomaines,  are  examples  of  other  groups 
of  chemical  irritants. 

A  septic  irritant  is  a  living  organism, — a  parasite,  a  micro-organ- 
ism,— causing  irritation  by  its  presence,  and  the  formation  of  poisons, — 
ptomaines, — as  waste  products,  and  their  introduction  into  the  system. 
The  pus-microbes  and  the  saprophytic  germs  belong  to  this  class. 

A  nervous  irritant  is  one  which  produces  irritation  through  the 
medium  of  the  nervous  system.  The  influence  exerted  by  the  nervous 
system  over  the  functions  of  nutrition,  both  generally  and  locally,  and 
in  the  production  of  inflammatory  symptoms,  has  long  been  recog- 
nized. Impairment  of  the  nutrition  of  the  skin  is  sometimes  observed 
to  follow  injury  of  the  nerves  supplying  the  part.  Reflex  conditions 
are  also  recognized  as  productive  of  inflammation.  An  instance  in 
point  is  irritation  of  the  dental  pulp,  which  sometimes  occurs  in  preg- 
nant women,  tierpes  zoster  is  an  example  of  a  pustular  eruption  fol- 
lowing the  course  of  a  nerve,  and  is  accompanied  with  infiltration  of 
leucocytes,  both  around  the  terminal  branches  and  the  trunk  of  the 
nerve.    (Warren.) 

Irritation. — Definition :  To  excite,  to  stir  up,  to  inflame.  Irrita- 
tion is  the  state  of  a  tissue  or  an  organ  in  which  there  is  an  excess  of 
vital  movement,  commonly  manifested  by  increase  of  the  circulation 
and  the  sensibility.  Irritation  in  some  form  always  precedes  inflamma- 
tion, or,  in  other  words,  inflammation  is  always  caused  by  some  form 
of  irritation.  When  the  irritation  is  confined  to  a  particular  portion  of 
the  body,  it  is  termed  local  irritation.  Examples  would  be,  an  injury 
upon  the  surface  of  the  body;  infection  from  a  devitalized  tooth-pulp, 
etc.  When  the  irritation  aft'ects  the  whole  system,  it  is  termed  general 
or  constitutional  irritation.  Examples  would  be  the  presence  of  malarial 
poison  in  the  blood,  or  pyemia. 


40  surgery  of  the  face,  mouth,  and  jaws. 

Pathology  of  Inflammation, 

Inflammation  is  a  process  whicli  may  affect  any  tissue  of  the 
body  having  a  vascular  circulation,  or  which  is  connected  with  blood- 
vessels. It  begins  usually  with  the  phenomena  of  hyperemia,  and 
progresses  to  exudation  or  suppuration,  sometimes  healing,  sometimes 
leading  to  the  production  of  new  formations,  or  to  metamorphoses  of 
various  kinds,  or  to  death  and  destruction  of  tissue,  and  creating  a  more 
or  less  serious  disturbance  of  the  functions  of  the  parts.  The  disease 
may  vary  very  greatly  in  its  character  and  in  its  location.  The  histo- 
logic character  of  inflammations  depends  upon  two  factors :  the  nature 
of  the  exudation  and  the  changes  in  the  tissues.  Both  are  used  to 
classify  the  various  forms  of  inflammation,  according  as  the  one  or  the 
other  seems  to  be  the  most  pronounced. 

Hyperemia. — The  condition  known  as  hyperemia  is  one  of  the 
most  elementary  physical  disturbances  in  the  realm  of  surgical  pathol- 
ogy, and  occupies  a  position,  both  physiologic  and  pathologic,  that  is 
difficult  to  define.  A  hyperemia  may  be  a  physiologic  expression  of  an 
emotion,  or  a  local  stimulation,  causing  an  accelerated  movement  of  the 
blood  in  a  given  part,  or  it  may  be  the  beginning  of  a  pathologic  con- 
dition induced  by  slight  injury,  or  the  entrance  into  the  circulation  of 
certain  noxse;  but  just  at  what  point  the  process  ceases  to  be  physio- 
logic and  becomes  a  pathologic  expression  cannot  be  demonstrated. 
Fig.  28  shows  capillary  blood-vessels  in  a  normal  condition,  with  the 
blood-corpuscles  passing  through  them. 

Definition:  Hyperemia  is  a  condition  in  which  there  is  an  in- 
creased amount  of  blood  in  a  part.  When  there  is  an  increased  amount 
of  blood  in  all  the  vessels  of  the  body,  it  is  termed  plethora.  The  oppo- 
site conditions  to  these  are,  ischemia,  a  decreased  flow  of  blood  to  a 
part,  and  anemia,  when  there  is  a  less  quantity  of  blood  in  the  body 
than  is  usual.  In  a  medical  sense,  the  latter  term  is  used  to  indicate 
certain  pathologic  conditions  in  the  character  of  the  blood. 

Hyperemia  may  be  a  physiologic  or  a  pathologic  condition. 
Flushing  of  the  cheeks,  as  the  result  of  mental  excitement  produced 
by  joy,  shame,  or  anger,  is  an  illustration  of  the  physiologic  hyper- 
emia; while  the  redness  following  a  local  irritation  would  more  nearly 
express  a  pathologic  hyperemia. 

Hyperemia  may  be  divided  into  two  forms,  generally  denominated 
active  and  passive;  the  difference  between  these  forms  being  that  in  act- 
ive hyperemia  there  is  an  increase  in  the  amount  of  arterial  blood  flow- 
ing into  the  part,  while  in  passive  hyperemia  there  is  a  slowing  of  the 
blood-current, — a  partial  or  complete  stagnation  of  the  movement  of 
the  blood  through  the  vessels.  Local  active  hyperemia  may  be  pro- 
duced through  various  forms  of  stimulation  applied  to  the  surface  of 
the  body,  acting  through  the  vaso-motor  system  of  nerves,  like  heat, 


INFLAMMATION. 


41 


cold,  mechanical  pressure,  rapid  blows  sufficiently  light  not  to  cause 
pain, — for  instance,  the  blows  of  the  hand,  mechanical  or  electric 
mallet  in  filling  teeth,  and  the  action  of  the  faradic  current.  The  stimu- 
lation by  the  faradic  current,  when  applied  to  the  surface  of  the  body, 
may  be  likened  to  the  mechanical  stimulation  of  that  form  of  massage 
known  as  hackcii, — rapid  and  light  blows  made  with  the  edges  of  the 
hands. 

Fig.  2^ 


Connective- 
tissue  cor- 
puscles pig- 
mented. 


Normal  Capillary  Vessels;   Blood-Corpuscles  in  them.    Branched  Connective- 
Tissue  Corpuscles  with  Pigment. 

Vulpian  demonstrated  the  vaso-motor  effects  upon  the  circulation 
by  faradic  stimulation  of  the  peripheral  segment  of  the  lingual  nerve  in 
a  dog.  He  found  as  a  result  of  this  stimulation  a  considerable  dilata- 
tion of  the  vessels  in  the  region  of  that  half  of  the  tongue  to  which  this 
nerve  has  its  distribution.  The  mucous  membrane  on  the  correspond- 
ing side  of  the  frenum  linguse  of  this  half  of  the  tongue  also  became 
bright  red,  while  the  principal  vein  became  turgescent,  and  the  blood, 
both  in  it  and  in  its  tributaries,  was  of  bright  color,  like  arterial  blood. 
There  wa3  also  a  perceptible  rise  in  the  temperature  of  the  part. 


42  SURGEKV    OF    THE    FACE,    MOUTH,    AND    JAWS. 

From  the  experiments  of  Claude  Bernard  and  others  upon  the 
physiologic  action  of  the  vaso-motor  system,  it  was  demonstrated  that 
section  of  the  sympathetic  nerve  would  produce  a  hyperemia  of  the 
part,  through  paralysis  of  the  vaso-constrictor  nerves.  Stimulation  of 
the  chorda-tympani  nerve  resulted  in  dilatation  of  the  blood-vessels  of 
the  submaxillary  gland.  This  served  to  prove  the  existence  of  two 
sets  of  nerves,  one  vaso-constrictors,  and  the  other  vaso-dilators,  which 
placed  the  vascular  system  under  the  control  of  the  vaso-motor  centers. 
There  is  also  a  system  of  periphero-vaso-motor  nerves,  under  the  con- 
trol of  what  is  known  as  the  perivascular  ganglia.  The  continuous 
action  of  these  ganglia  and  of  the  constrictors  secures  a  state  of  chronic 
contraction  of  the  muscular  walls  of  the  blood-vessels.  The  dilators 
come  into  action  only  under  exceptional  circumstances.  Strieker  is 
of  the  opinion  that  most  of  the  physiologic  and  pathologic  hyper- 
emias are  the  result  of  irritation  of  the  dilators.  The  existence  of  such 
a  system  of  nerves  and  ganglia  has  never  been  positively  demonstrated, 
either  anatomically  or  microscopically,  although  microscopic  clusters 
of  ganglia  have  been  discovered  upon  the  arteries  of  the  submaxillary 
glands,  and  in  other  locations. 

As  hyperemia  may  be  caused  by  paralysis  of  the  constrictors,  or  by 
irritation  of  the  dilators,  two  forms  of  active  hyperemia  may  be  recog- 
nized. When  caused  by  paralysis  of  the  constrictors,  it  is  known  as 
hyperemia  of  paralysis.  When  caused  by  irritation  of  the  dilators,  it  is 
known  as  hyperemia  of  irritation.  (Warren.)  These  elements,  which 
combine  to  form  the  vaso-motor  system,  are  so  nicely  adjusted  that 
they  counteract  each  other,  and  when  disturbances  arise  in  the  circula- 
tion in  one  direction,  a  reaction  in. the  opposite  way  may  soon  occur  to 
restore  the  normal  condition. 

Injuries  of  various  forms  which  afifect  the  sympathetic  nerves  are 
the  most  common  cause  of  the  hyperemia  of  paralysis.  Warren  men- 
tions a  case  in  his ,  hospital  service  in  which  injury  to  the  cervical 
sympathetic  was  immediately  followed  by  changes  in  the  pupil,  and 
hyperidrosis  of  the  injured  half  of  the  face  and  neck.  Syncope 
following  blows  upon  the  chest  and  abdomen,  and  resulting  in  death  or 
recovery,  are  the  result,  no  doubt,  of  reflex  paralysis  of  the  heart  and 
abdominal  vessels. 

Blushing  and  the  redness  of  the  face  following  the  use  of  tea^ 
coffee,  and  alcoholic  stimulants  are  considered  hyperemias  of  dilatation. 
This  form  of  hyperemia  also  accompanies  the  pain  of  facial  neuralgia, 
causing  flushing  of  the  forehead  and  face,  redness  of  the  conjunctiva, 
and  secretion  of  tears.  It  is  also  associated  with  hemicrania,  and  with 
certain  forms  of  peripheral  disturbances  of  the  nervous  system,  the  pro- 
duction of  herpes  zoster  being  a  marked  example.  Recklinghausen  is 
of  the  opinion  that  all  reflex  hyperemias  are  hyperemias  of  dilatation. 


INFLAMMATION. 


43 


The  hyperemia  observed  in  parts  separated  from  the  nerve-centers, 
Hke  transplantation  flaps,  and  in  other  portions  of  the  body  which  have 
been  separated  by  division  of  the  nerves,  is  caused  by  paralysis  of  the 
perivascular  ganglia. 

Exudation. — Exudation  is  the  process  by  which  the  corpuscular 
elements  of  the  blood  and  the  liquor  sanguinis  pass  through  the  walls 
of  the  blood-vessels  into  the  tissue  spaces  beyond.  Exudation  is  the 
result  of  changes  in  the  vessel-walls,  which  permit  the  passage  or 
leakage  of  the  circulating  fluid  through  them.  Ziegler  says,  "It  may 
be  accepted  as  an  established  fact  that  in  inflammation  the  vessel-wall 
is  afifected,  but  it  is  still  questioned  by  some  whether  the  affection  is  of 
the  nature  of  a  chemical  alteration,  or  a  mere  widening  of  pre-existing 
intercellular  spaces."  Burdon  Sanderson  believes  that  "it  is  due  to 
the  loss  of  the  power  by  the  vessels  of  resistance  to  dilatation,  and  the 
loss  of  vital  power,  in  consequence  of  which  leakage  takes  place." 

Inflammation  is  divided  into  two  forms,  viz:  acute  and  chronic; 
and  these  again  into  many  varieties,  according  to  the  anatomical  loca- 
tion of  the  disease,  as  taught  by  Virchow,  such  as  catarrhal,  fibrinous, 
parenchymatous,  phlegmonous,  indurative,  degenerative,  scrofulous, 
and  infective. 

In  acute  inflammation  the  disease  runs  a  more  or  less  rapid 
course,  and  the  symptoms  are  marked,  while  in  the  chronic  form  the 
symptoms  are  all  less  prominent,  and  any  or  all  of  the  cardinal  signs 
may  be  so  slight  as  to  escape  notice  altogether.  A  form  between  these 
two  conditions  has  been  denominated  subacute  inflammation. 

Catarrhal  inflammation  is  an  inflammatory  condition  of  the  mu- 
cous membrane  in  particular,  wherever  found  in  the  body. 

Fibrinous  inflammation  may  be  regarded  as  the  usual  form 
found  in  serous  membranes  and  the  connective  tissue.  Fibrinous 
exudates,  however,  often  form  upon  mucous  surfaces,  as  in  diphtheria 
and  membranous  croup. 

Parenchymatous  inflammation  is  a  term  applied  to  those  changes 
which  take  place  in  the  special  tissues  of  organs,  independent  of  the 
connective-tissue  framework, — affecting  the  elementary  components 
of  a  tissue, — the  cellular  elements, — and  expressed  by  a  tendency  to 
effusion  of  plastic  material  from  the  blood-vessels. 

Phlegmonous  inflammation  is  principally  confined  to  the  connective 
tissue  in  the  form  of  abscesses. 

Indurative  inflammation  is  that  variety  which  is  productive  of  new- 
tissue  formations  in  the  interior  of  organs. 

Degenerative  inflammation  may  attack  any  of  the  tissues,  and  pro- 
duce a  retrograde  metamorphosis  in  their  structure.  Examples  are 
fatty  degeneration,  caseation,  calcareous  degeneration,  etc. 

Scrofulous  inflammation — the  use  of  this  term  is  now  questioned 


44  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

by  good  authorities — is  a  type  of  inflammation  occurring  in  cachectic 
individuals,  whose  tissues  injure  easily  and  heal  slowly,  and  are  prone 
to  degenerative  changes. 

Infective  inflammation  is  produced  by  the  introduction  into  the 
blood  of  infective  materials,  usually  derived  from  the  entrance  of  bac- 
teria, or  from  some  pre-existing  inflammation.  Examples  are  erysip- 
elas, pyemia,  tuberculosis,  syphilis. 

The  terms  idiopathic  and  traumatic,  as  applied  to  inflammation,  are 
now  considered  as  obsolete. 

General  InHammation  is  the  condition  known  as  fever.  Fever  in- 
volves a  rise  in  the  body  temperature,  weakening  and  acceleration  of 
heart-action,  disturbances  of  the  nervous  system,  and  interruption  in 
all  of  the  processes  of  nutrition. 

Temperature. — The  normal  temperature  of  the  body  is  98.5° 
Fahrenheit.  When  it  rises  above  this  it  indicates  fever;  when  it 
falls  below  it  indicates  shock  or  collapse.  A  temperature  of  105° 
is  generally  considered  dangerous,  while  107°  is  usually  fatal. 
It  rarely  occurs  that  the  temperature  reaches  a  higher  degree 
than  this,  though  exceptional  cases  are  on  record  which  reached  110° 
to  112°.  Richet  recently  called  the  attention  of  the  Biological  Society 
of  Paris  to  a  remarkable  case  of  hyperpyrexia  in  a  woman  suffering 
from  intermittent  fever.  While  the  temperature  in  the  morning  was  no 
higher  than  102°  Fahrenheit,  in  the  evening  it  ascended  to  113°. 
Upon  two  difiterent  occasions  it  rose  to  114.8°.  The  utmost  care  was 
used  to  avoid  deception.  Moreover,  under  the  influence  of  quinin,  it 
fell  to  96.8°,  and  when  the  quinin  was  suspended,  the  temperature 
rose  again  to  118.8°.  After  a  fresh  exacerbation  of  longer  continu- 
ance, the  temperature  fell  to  normal,  and  the  patient  recovered. 

In  fevers  generally  the  temperature  is  highest  in  the  evening  and 
lowest  in  the  morning.  In  the  fever  accompanying  difficult  dentition, 
it  is  generally  the  reverse  of  this,  viz,  highest  in  the  morning  and 
lowest  in  the  evening. 

Pulse. — The  normal  pulse  in  an  adult  is  about  75  beats  per  minute. 
In  infants  it  ranges  from  120  to  140  per  minute.  Very  old  persons 
have  a  much  higher  pulse-rate  than  people  in  middle  life.  A  full, 
rapid,  bounding  pulse  is  indicative  of  high  fever,  and  bears  a  relative 
ratio  to  the  increase  in  bodily  temperature.  For  instance,  a  tempera- 
ture of  103°  would  be  accompanied  with  a  pulse-rate  of  about  100.  A 
soft,  rapid,  small,  flowing  pulse  is  indicative  of  great  weakness,  and  of 
collapse  if  occurring  in  fevers.  The  pulse  in  severe  cases  of  pneu- 
monia may  run  from  120  to  130  beats  per  minute.  An  irregular  or 
intermittent  pulse  is  indicative  of  functional  or  organic  disease  of  the 
heart. 


inflammation.  45 

Symptoms  of  Acute  Local  Inflammation. 

Redness. — This  symptom  is  persistent,  and  is  due  to  hyperemia. 
By  digital  pressure  the  capillaries  can  be  emptied,  but  on  removing 
the  pressure  the  redness  immediately  returns.  The  shade  of  color  de- 
pends upon  the  freedom  from  obstruction  in  the  vessels,  and  the  rapid- 
ity of  the  circulation.  When  the  color  is  dark  or  purplish  it  denotes 
stasis;  rose-red  streaks  along  the  track  of  the  lymph-vessels  indicate 
lymphangitis;  a  dark  red  track  along  the  course  of  the  veins  would 
point  to  phlebitis;  while  a  copper-red  color  would  denote  syphilitic 
inflammation. 

Szvelling. — This  symptom  is  due  to  the  engorgement  of  the  blood- 
vessels of  the  part,  to  exudation  from  the  blood-vessels,  and  to  prolif- 
eration of  cells.  In  acute  inflammations  the  swelling  is  soft;  in  the 
chronic  forms  it  is  hard.  Swelling  is  especially  marked  in  loose  con- 
nective tissue. 

Heat. — This  symptom  is  most  marked  at  the  center  or  focus  of 
the  inflamed  area.  It  is  thought  to  be  produced  by  the  increased  rapid- 
ity of  the  circulation,  and  the  volume  of  blood  in  the  part.  Hunter 
taught  that  the  heat  of  the  part  was  never  above  the  heat  of  the  internal 
organs.  Hunter's  Law  reads  as  follows:  "In  inflammation  the  heat  of 
the  part  is  increased  above  the  normal  temperature  of  the  part,  but  not 
beyond  the  temperature  of  the  internal  organs." 

Pain. — This  symptom  is  persistent,  and  is  increased  by  pressure, 
by  motion  of  the  part,  or  by  general  exercise.  Exercise  increases  ar- 
terial tension,  and  thus  augments  the  pain.  The  pain  is  most  intense 
in  dense  structures,  and  is  mainly  due  to  mechanical  pressure  upon  the 
nerve-filaments,  and  is  sometimes  reflected  to  regions  remote  from  the 
seat  of  the  inflammation.  Examples  are,  knee  pain  in  hip-joint 
disease,  shoulder  pain  in  hepatitis,  otalgia  in  pulpitis. 

Disturbance  of  Function. — This  symptom  is  marked  in  its  action 
upon  the  secretions,  which  often  become  perverted  or  suppressed. 
The  reflexes  are  generally  exaggerated.  Examples  are  the  tenesmus 
of  dysentery,  the  strangury  of  cystitis,  the  convulsions  of  teething. 
Non-sensitive  parts  become  hypersensitive,  examples  being  the  pain  of 
pleurisy,  peritonitis,  teething,  or  decayed  dentine  in  vital  teeth. 

Description  of  the  Inflammatory   Process   in   the   Vascular 

Tissues. 

The  phenomena  of  inflammation  in  the  vascular  tissues  are  best 
studied  in  the  tongue,  the  mesentery,  or  the  web  of  the  frog's  foot. 
A  good  microscope  is  indispensable. 

The  process  may  be  divided  and  briefly  described  in  the  follow- 
ing order:  Irritation,  Hyperemia,  Expansion  of  Blood-vessels,  Re- 
tarded Flow  of  Blood,  Migration  of  Leucocytes,  Exudation  of  Liquor 


46 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


Sanguinis,  Partial  Stasis,  Resolution,  Complete  Stasis,  Suppuration, 
Ulceration,  Gangrene,  Necrosis,  Somatic  Death. 

Irritation,  in  some  of  its  forms, — traumatism,  heat,  cold,  acids, 
alkalies,  vesicants,  micro-organisms,  and  their  products, — is  always 
necessary  to  establish  the  phenomena  of  inflammation  in  the  vas- 
cular tissues. 

Hyperemia  is  caused  by  an  increased  flow  of  blood  to  the  part,  as 
a  result  of  the  stimulation  of  irritation. 


Fig.  29. 


Fibroblasts. 


Fibroblasts. 


Inflammation,  showing  Migration  of  the  Leucocytes. 


Expansion  of  blood-vessels  results  from  the  increased  flow  or 
volume  of  blood  entering  them,  and  paralysis  of  their  muscles. 

Retarded  Hozv  of  blood  is  caused  by  the  continued  expansion  of  the 
blood-vessels,  and  adhesion  of  the  leucocytes — colorless  blood-cor- 
puscles— to  the  sides  of  the  vessels.  This  stage  in  the  process  consti- 
tutes acute  congestion. 

Migration  of  leucocytes   (diapedesis).     These  corpuscles  escape 


inflammation. 
Fig.  30. 


47 


Connective 
tissue. 


inflammatory 
exudates. 


lood- 
essels. 


Inflammation  of   the   Pericementum,  showing   Inflammatory   Exudates.     (After  Talbot.) 

X4S0. 


Fig.  31. 


Inflammatory 
«xudates. 


V.  •*  1     Connective- 

tissue-fibers. 


Migrated 
cells. 


Inflammation  of  the  Pericementum,  showing  Migrated   Blood-Cells,  and  Coagulum  of 
Plasma.     (After  Talbot.)     X.480. 


48 


SURGERY    OF   THE    FACE,    AIOUTH,    AND    JAWS. 
Fig.  32. 


.^^.v^€A^% 


ji?. 


Jtnij: 


Inflammation  of  the  Pericementum,  showing  Connective-Tissue  Spaces  crowded  with 
Inflammatory  Exudates  preceding  Stasis.     (After  Talbot.)     X  480. 


Fig.  33. 


Inflammation  of  the  Pericementum,  showing  Stage  of  Degeneration  and  commencing 
Liquefaction  of  Tissue.    (After  Talbot.)    X  480. 


INFLAMMATION.  49 

throiig;h  the  walls  of  the  vessels  by  an  ameboid  movement,  and  collect  in 
the  meshes  of  the  connective  tissues  (Fig.  29).  The  red  corpuscles  also, 
in  some  instances,  pass  through  the  vessel-walls,  but,  not  having  the 
power  of  migration,  they  are  consequently  found  in  the  immediate 
neighborhood  of  the  blood-vessels. 

Exudation  of  liquor  sanguinis  causes  induration  and  swelling, 
accompanied  by  coagulation  of  the  fibrinous  elements.  The  coagula- 
tion of  this  plasma  incloses  the  migrated  corpuscles,  and  thereby  pre- 
vents their  further  movement.     (Figs.  30,  31.) 

Partial  stasis.  The  leucocytes  adhere  to  the  walls  of  the  vessels'. 
The  liquor  sanguinis  separates  and  flows  in  a  current  next  to  the  walls 
(plasma  layer),  while  the  red  corpuscles  move  in  a  stream  through  the 
center  (axial  stream),  occasionally  stopping  for  a  moment,  and  then 
slowly  moving  on  again  in  an  irregular  manner. 

Resolution.  At  this  stage,  resolution — a  return  to  normal  func- 
tion— may  take  place  under  favorable  conditions.  The  blood-current 
gradually  resumes  its  natural  flow;  resorption  of  the  exudation  takes 
place,  the  induration  and  swelling  disappear,  the  pain  ceases,  and  the 
tissues  regain  their  normal  color,  or  complete  stasis  takes  place. 

Complete  stasis  is  that  condition  in  which  the  circulation  of  the 
blood  is  completely  arrested  in  a  more  or  less  extensive  portion  of  the 
inflamed  tissue.  (Fig.  32.)  When  this  occurs,  gangrene  and  necrosis 
are  the  result,  and  it  may  be  followed  by  suppuration. 

Suppuration  (molecular  death).  In  suppuration  the  exuded 
blood-corpuscles  or  leucocytes  lose  their  vitality.  Originally  they 
were  tissue-builders,  thrown  out  to  repair  damages;  failing  in  this, 
degeneration  and  liquefaction  take  place  (Fig.  33);  they  form  with 
the  exuded  liquor  sanguinis  a  thick  creamy  substance  known  as  pus. 

Ulceration  (molecular  death  of  tissue).  This  process  causes  a 
break  in  the  continuity  of  the  tissues,  and  is  accompanied  by  a  dis- 
charge. The  surfaces  become  vascularized,  and  are  converted  into 
granulations;  or 

Gangrene  (slough — death  en  masse  of  soft  tissue).  This  condition 
is  the  result  of  complete  stasis.  The  soft  tissues  are  cut  off  from  their 
nutrient  supply,  lose  their  vitality,  and  slough  away  in  portions 
corresponding  to  the  area  thus  involved. 

Necrosis  (exfoliation — death  en  masse  of  bony  tissue).  The  hard 
tissues,  when  deprived  of  their  blood-supply,  also  die  en  masse,  separa- 
tion finally  takes  place  between  the  vital  and  the  non-vital  parts,  and 
the  necrosed  portion  is  exfoliated. 

Somatic  death  is  death  of  the  whole  body. 

In  the  further  study  of  this  subject  the  term  necrosis  will  be  ap- 
plied to  death  en  masse  of  bone-tissue  only.* 

*The  above  division  of   the  various  processes  in  inflammation  is  somewhat 

5 


50  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

Vital  Resistance. — The  resistance  of  the  hody  and  of  individual 
tissues  against  the  invasion  of  the  micro-organisms  which  produce  dis- 
ease depends  upon  the  state  of  vitality  of  the  general  system  and  of 
the  tissues  affected.  The  tissues  of  the  body  are  never  entirely  passive 
in  the  presence  of  disease-producing  bacteria,  but  there  is  a  marked 
difference  at  certain  periods  in  the  amount  of  resistance  exhiljited  by 
the  general  system  and  by  the  tissue-cells.  This  is  particularly  noticed 
in  individuals  who  are  in  a  debilitated  condition  and  in  tissues  whose 
nutrition  is  impaired  as  the  result  of  previous  disease  or  injury.  In 
this  respect  the  white  corpuscles  or  leucocytes  of  the  blood  are  thought 
to  play  an  important  part.  Metchnikoff  claims  that  diapedesis — the 
migration  of  the  leucocytes — is  nature's  method  of  defending  herself 
against  the  invasion  of  the  tissues  by  a  foreign  substance  or  living  para- 
site. When  an  irritant  of  any  sort  has  made  an  impression  upon  the 
tissues  the  leucocytes  immediately  hasten  to  that  point  in  great  numbers, 
emerging  from  the  vessels  and  opening  a  vigorous  attack  upon  the  in- 
vading adversary.  In  this  attack  they  attempt  to  destroy  the  enemy 
by  either  englobing  and  digesting  the  smaller  elements,  like  the  patho- 
genic micro-organisms,  or  by  surrounding  the  larger  bodies  en  masse 
and  exerting  their  digestive  functions  upon  them  through  the  larger 
multinucleated  cells.  If  the  leucocytes  overcome  the  invading  adversary 
the  acute  symptoms  of  the  irritation  subside  and  resolution  is  estab- 
lished. If,  on  the  other  hand,  the  resistance  of  the  leucocytes  and  of 
the  tissues  is  too  feeble  to  overcome  the  intruder,  the  acute  symptoms 
progress  and  the  leucocytes  lose  their  vitality  and  are  converted  into 
what  are  termed  pus-corpuscles,  and  an  abscess  is  formed. 

The  power  of  the  leucocytes  and  of  certain  other  cells  to  destroy 
bacteria  and  other  solid  elements  which  gained  access  to  the  tissues 
and  the  blood,  Metchnikoff  termed  "phagocytosis/"  and  the  cells  pos- 
sessing this  power  "phagocytes." 

Phagocytosis  (Greek  </)ayeTv,  to  eat ;  /cvVos,  a  cell ). — Definition.  The 
destruction  or  taking  up  of  micro-organisms  or  other  solid  ele- 
ments by  living  cells,  as  by  the  colorless  blood-corpuscles.  A  "phago- 
cyte" is,  according  to  Metchnikoff,  one  of  the  motile,  ameboid,  digestive 
cells  or  metazoa,  moving  from  place  to  place  in  the  organism  under 
the  influence  of  thermotaxis,  or  of  positive  or  negative  chcmiotaxis. 
They  are  believed  to  take  up  within  their  interior  the  remains  of  larval 
organs,  degeneration  products  or  excretion  products,  foreign  particles, 
schizomycetes,  hematozoa,  etc.,  their  activity  varying  as  the  logarithm 
of  the  excitation.  These  cells  are  sometimes  known  as  the  wandering 
cells  of  Ziegler.     They  are  found  in  a  limited  degree  in  acute  inflam- 

arbitrary,  but  the  writer  believes  that  by  this  plan  the  student  will  better  under- 
stand and  retain  the  subject. 


INFLAMMATION.  5 1 

matory  processes,  but  are  very  abundant  in  chronic  forms  of  inflamma- 
tion.   Their  origin,  however,  is  still  a  matter  of  dispute. 

The  power  of  the  leucocytes  to  take  up  solid  particles  and  por- 
tions of  broken-down 'and  disintegrated  blood-corpuscles  was  observed 
by  Recklinghausen,  Rindtleisch,  Ponfick,  and  others  as  far  back  as 
1860-70.  Ziegler,  in  1874,  observed  the  fibroblasts  of  granulation- 
tissue  take  up  and  destroy  leucocytes. 

Koch  discovered,  1878,  in  studying  mouse  septicemia,  that  the 
slender  bacillus  which  is  the  cause  of  the  disease  was  found  in  great 
numbers  in  the  interior  of  the  leucocytes,  he  believed  they  penetrated 
these  cells  and  destroyed  them.  He  says :  "The  relation  of  the  bacilli 
to  the  leucocytes  is  peculiar ;  they  penetrate  these  cells  and  multiply 
within  their  interior.  One  often  finds  that  there  is  hardly  a  single 
white  corpuscle  in  the  interior  of  which  bacilli  cannot  be  seen.  Many 
corpuscles  contain  isolated  bacilli  only ;  others  have  thick  masses  in  their 
interior,  the  nucleus  being  still  recognizable,  while  in  others  the  nu- 
cleus can  no  longer  be  distinguished ;  and,  finally,  the  corpuscles  may 
become  a  cluster  of  bacilli,  breaking  up  at  the  margin, — the  origin  of 
which  could  not  have  been  explained  had  there  been  no  opportunity  of 
seeing  all  of  the  intermediate  steps  between  the  intact  white  corpuscle 
and  these  masses."  By  this  it  will  be  noticed  that  Koch  states  that  the 
bacilli  enter  the  leucocytes  and  multiply  within  their  interior  until  in 
some  instances  the  integrity  of  the  cell  is  destroyed. 

Surgeon-General  Geo.  M.  Sternberg,  U.  S.  A.,  observed  (1881) 
that  the  white  blood-corpuscles  had  the  power  sieemingly  to  capture  and 
destroy  living  pathogenic  bacilli.  He  says,  "It  has  occurred  to  me  that 
possibly  the  white  corpuscles  may  have  the  office  of  picking  up  and 
digesting  bacterial  organisms  which  by  any  means  find  their  way  into 
the  blood.  The  propensity  exhibited  by  the  leucocytes  for  picking  up  in- 
organic granules  is  well-known,  and  that  they  may  be  able  not  only 
to  pick  up  but  to  assimilate,  and  so  dispose  of,  the  bacteria  which  come 
in  their  way,  does  not  seem  to  me  very  improbable,  in  view  of  the  fact 
that  amebse,  which  resemble  them  so  closely,  feed  upon  bacteria  and 
similar  organisms."  Metchnikofif  at  a  later  period  (1884)  offered  ex- 
perimental evidence  in  favor  of  this  view,  and  claimed  further  that  by 
the  power  of  the  leucocytes  to  pick  up  and  destroy  the  invading  patho- 
genic bacteria,  immunity  was  established  in  the  organism.  He  found 
in  certain  observations  made  upon  a  species  of  daphnia,  which  is  sub- 
ject to  fatal  infection  by  a  torula  resembling  the  yeast  fungus  which 
enters  the  body  with  its  food,  that  this  fungus  penetrates  the  walls  of 
the  intestines  and  invades  the  tissues.  In  certain  cases  the  infection 
was  not  fatal,  and  this  he  believed  was  due  to  the  fact  that,  the  leuco- 
cytes, which  accumulated  around  the  invading  fungi,  seized  upon  them 
and  destroyed  them.    If  the  leucocytes  were  successful  in  overpowering 


52  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

the  parasites,  the  animal  recovered ;  if  not,  the  infection  proved  fatal. 
From  this  he  argued  that  the  pathogenic  bacteria  when  introduced  into 
the  body  of  an  immune  animal  are  destroyed  in  like  manner,  while  they 
play  an  active  part  as  prophylactic  agents  and  in  the  metamorphosis  of 
tissues  and  organs  in  inflammation. 

Metchnikoff  and  his  followers  maintain  that  the  bacilli  are  gathered 
up  by  the  leucocytes  and  destroyed  in  their  interior  by  a  digestive  pro- 
cess, and  that  immunity  to  infection  largely  depends  upon  the  power 
of  the  phagocytes  to  overcome  and  destroy  the  living  pathogenic  bac- 
teria which  have  gained  an  entrance  to  the  tissues  of  the  body.  Stern- 
berg, Weigert,  Baumgarten,  and  others  do  not  endorse  this  view,  for  it 
is  possible,  they  maintain,  that  the  bacteria  found  in  the  phagocytes 
were  already  dead  when  taken  up  by  these  cells,  their  vitality  having 
been  destroyed  by  some  agency  outside  of  the  leucocytes,  namely,  the 
blood-serum,  and  there  is  abundant  experimental  evidence  to  prove 
that  the  blood-serum  has  decided  germicidal  power., 

The  question,  however,  as  to  whether  the  phagocytes  really  devour 
living  pathogenic  bacteria  and  by  this  process  overcome  their  action 
upon  the  tissues  and  establish  immunity  to  infectious  diseases  has  not 
yet  been  clearly  established. 

Sternberg  says  (1892),  "Numerous  experiments  have  been  made 
during  the  past  two  or  three  years  with  a  view  to  determining  whether 
pathogenic  bacteria  are,  in  fact,  destroyed  within  the  leucocytes  after 
being  picked  up,  and  different  experimenters  have  arrived  at  different 
conclusions.  In  the  case  of  mouse  septicemia,  already  alluded  to,  and 
in  gonorrhea,  one  would  be  disposed  to  decide  from  the  appearance 
and  the  arrangement  of  the  pathogenic  bacteria  in  the  leucocytes,  that 
they  are  not  destroyed,  but  that,  on  the  other  hand,  they  multiply  in 
the  interior  of  these  cells,  which  in  the  end  succumb  to  this  parasitic 
invasion.  In  both  of  the  diseases  mentioned  we  find  leucocytes  so 
completely  filled  with  the  pathogenic  micro-organisms  that  it  is  difficult 
to  believe  that  they  have  all  been  picked  up  by  a  voracious  phagocyte, 
which  has  stuffed  itself  to  repletion,  while  numerous  other  leucocytes 
from  the  same  source  and  in  the  same  microscopic  field  of  view  have 
failed  to  capture  a  single  bacillus  or  micrococcus.  Moreover,  the  stain- 
ing of  the  parasitic  invaders,  and  the  characteristic  arrangement  of  the 
"gonococcus"  in  stained  preparations  of  gonorrheal  pus,  indicate  that 
their  vitality  has  not  been  destroyed  in  the  interior  of  the  leucocytes  or 
pus  cells,  and  we  can  scarcely  doubt  that  the  large  number  found  in  cer- 
tain cells  is  due  to  multiplication  in  situ  rather  than  to  an  unusual 
activity  of  these  peculiar  cells.  But  in  certain  infectious  diseases,  and 
especially  in  anthrax,  the  bacilli  included  within  the  leucocytes  often 
give  evidence  of  degenerative  changes  which  would  support  the  view 
that  they  are  destroyed  by  the  leucocytes,  unless  these  changes  occurred 
before  they  were  picked  up,  as  maintained  by  Nuttall  and  others." 


INFLAMMATION.  53 

Nuttall  (1888)  has  shown  that  the  destruction  of  virulent  micro- 
organisms in  the  blood  of  animals  was  not  dependent  alone  upon  the 
immediate  presence  of  living  leucocytes,  but  that  the  serum  of  the 
blood  when  freed  from  all  cellular  elements  of  any  kind  still  possessed 
the  power  of  destroying  the  vitality  of  bacterial  forms  in  an  equal 
degree  to  that  of  the  blood  in  its  normal  state  when  all  of  its  constituent 
elements  were  present. 

Buchner  (1890)  demonstrated  that  the  serum  was  robbed  of  its 
germicidal  properties  by  exposure  to  a  temperature  of  55°  C.  for  half 
an  hour.  Its  efficiency,  on  the  other  hand,  was  not  impaired  by  alter- 
nately freezing  and  thawing  it;  but  dialysis  or  extreme  dilution  with 
distilled  water  diminished  its  germicidal  power  or  completely  destroyed 
it.  If,  however,  it  was  diluted  with  an  equal  amount  of  water  contain- 
ing from  0.6  to  0.7  per  cent,  of  sodium  chlorid  its  germicidal  action 
was  in  no  way  diminished.  From  this  he  came  to  the  conclusion  that 
the  active  element  or  agent  in  the  blood  which  confers  this  power  upon 
it,  is  a  living  albumin,  and  that  an  essential  constituent  is  sodium 
chlorid,  the  removal  of  which  either  by  dialysis  or  dilution  robbed  the 
blood  of  its  germicidal  power.  For  those  constituents  of  the  blood 
which  possess  this  bactericidal  power  he  proposed  the  term  "alexins." 
Hankin,  Martin,  and  Agatta  (1891)  have  succeeded  in  isolating  fer- 
ment-like "globulins"  which  in  solution  possess  active  germicidal 
powers. 

Vaughn,  Novy,  and  McClintock  have  found  in  their  observations 
that  the  nucleins  are  the  most  important  germicidal  and  protective 
agents  possessed  by  the  body.  That  this  bactericidal  constituent  of  the 
blood-serum  is  not  a  serum  albumin,  but  that  it  is  a  proteid,  for  it  is 
destroyed  at  65°  C,  and  that  it  is  probably  a  nuclein,  for  it  is  not  de- 
stroyed by  gastric  digestion.  The  nuclein  which  they  isolated  was  found 
to  possess  most  powerful  germicidal  properties  when  tested  upon 
Koch's  comma  bacillus,  the  streptococcus  pyogenes  aureus,  and  the  ba- 
cillus anthracis. 


CHAPTER  IV. 

INFLAMMATION  (Continued). 
Suppuration. 

Definition. — Suppuration.  (Lat.  suppuratio,  from  suppurare,  to 
form  pus.)     The  formation  of  pus. 

Suppuration  is  the  most  common  or  frequent  termination  of  acute 
inflammation.  An  inflammation  which  terminates  in  this  manner  is 
termed  Suppurative  Inflammation. 

Suppuration  is  a  process  by  which  the  morphologic  elements 
produced  by  the  inflammation — the  leucocytes  and  the  embryonic  cells 
formed  from  the  fixed  tissue-cells — are  converted  into  pus-corpuscles, 
and  the  intercellular  substance  of  the  tissues  is  liquefied. 

"Suppuration  takes  place  in  the  tissues  by  virtue  of  the  peculiar 
peptonizing  or  digestive  action  which  the  bacteria  exert  upon  them." 
(Warren.) 

When  pus  collects  and  forms  an  abscess  it  exerts  a  solvent  action 
upon  the  tissues,  as  evidenced  by  the  presence  of  broken-down  tissue- 
cells  and  remains  of  tissue,  mixed  with  pus-corpuscles.  There  must 
therefore  be  some  chemical  substance  in  the  pus  which  sets  up  this 
solvent  or  digestive  action. 

The  direct  cause  of  suppuration  is  the  action  of  certain  specific 
micro-organisms — the  pus-microbes — upon  the  tissues,  the  leucocytes, 
and  the  embryonic  cells. 

Pus  may  be  produced,  however,  under  given  circumstances,  with- 
out the  presence  or  intervention  of  micro-organisms;  as,  for  instance, 
by  the  introduction  under  the  skin  of  certain  chemical  irritants. 

Heuter  and  his  school  took  a  radical  position  in  reference  to  the 
power  of  micro-organisms  to  cause  the  production  of  pus,  and  stated 
that  there  could  be  no  pus  without  bacteria.  This  statement  met  with 
strong  dissent  on  the  part  of  many  close  observers,  who  were  not 
ready  to  grant  such  complete  control  to  the  ubiquitous  microbe. 

Billroth  believed  that  bacteria  were  not  the  cause  of  suppuration, 
but  only  an  accompaniment,  and  that  the  active  cause  was  a  chemical 
ferment.  Pasteur  and  others  claimed  to  prove  this  position,  by  pro- 
ducing suppuration  with  pus  which  had  been  subjected  to  a  sufficient 
degree  of  heat  to  destroy  the  bacteria  contained  in  it.     It  was  also 

54 


INFLAMMATION.  55 

found  by  experiment  that  certain  chemical  substances  inserted  under 
the  skin  would  produce  pus.  Councilman  first  proved  the  fact  that 
croton  oil  when  injected  under  the  skin  in  rabbits  would  produce  sup- 
puration without  the  action  of  micro-organisms.  The  early  experi- 
ments in  this  line  were  very  conflicting;  some  observers  succeeded  in 
producing  an  aseptic  pus, — others  a  septic  product,  with  the  same 
chemical  agent.  Christmas  could  not  produce  suppuration  in  rabbits 
with  turpentine  or  mercury,  but  succeeded  with  dogs.  These  conflict  - 
ing  results  were  due  in  some  cases  to  imperfect  asepsis,  in  others  to  the 
fact  that  the  same  chemical  substance  would  produce  suppuration  in 
one  species  of  animal,  and  not  in  another.  Warren  says,  "It  must  be 
conceded  that  it  is  possible  to  produce  suppuration  without  the  direct 
intervention  of  bacteria,  but  all  (authorities)  are  agreed  that  mechan- 
ical irritation  or  foreign  bodies  are  unable  to  produce  suppuration 
without  the  aid  of  bacteria." 

Senn  believes  all  inflammatory  wound  complications,  including 
suppuration,  are  caused  by  the  introduction  into  the  tissues  of  patho- 
genic micro-organisms,  the  clinical  varieties  being  mostly  determined 
by  the  intensity  of  the  infection,  the  manner  of  localization,  and  the 
degree  of  resistance  possessed  by  the  tissues.  The  same  streptococcus 
which  produces  a  simple  abscess  is  likewise  the  most  frequent  cause  of 
progressive  gangrene,  and  of  that  most  grave  form  of  suppuration 
known  as  pyemia. 

In  suppurative  inflammation  two  forms  of  leucocytes  are  found; 
one  is  mononucleated,  the  other  polynucleated.  (Warren.)  The 
former  is  found  only  in  limited  degree  in  the  early  stages  of  suppura- 
tion in  acute  inflammation,  but  in  its  later  stages,  and  in  the  chronic 
forms  of  inflammation,  it  is  present  in  greater  numbers.  They  are 
derived  from  the  blood,  and  from  the  fixed  tissue-cells.  The  poly- 
nucleated are  the  wandering  cells,  described  by  Ziegler.  They  are  dis- 
tinguished from  the  pus-cells  by  the  larger  size  of  the  nucleus.  The 
polynucleated  cells  possess  two  or  three  nuclei,  or  the  nucleus  is  pe- 
culiarly deformed.  This  change  in  the  shape  of  the  nucleus  does  not 
seem  to  be  the  beginning  of  the  karyokinetic  process — cell  division — 
but  rather  one  of  degeneration  preceding  the  final  breaking  down  of 
the  corpuscles.  A  few  tissue-cells  are  also  found  mixed  with  the  pus- 
corpuscles.  The  polynucleated  cells  may  be  considered  as  a  type  of 
the  pus-corpuscle. 

In  addition  to  the  cells  already  mentioned,  there  are  found  larger 
cells,  with  a  single  large,  bright,  oval  nucleus,  known  as  "fibroblasts." 
These  in  the  later  stages  of  suppuration  increase  in  numbers  until  they 
become  more  numerous  than  the  pus-corpuscles,  and  are  the  active 
agents  in  the  process  of  repair. 

The  indirect  causes  of  suppuration  are  the  inflammatory  phenomena 


'.$6  SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 

of  exudation,  the  crowding  of  the  connective-tissue  spaces  with  the 
corpuscular  elements  of  the  blood  and  the  consequent  pressure  upon 
the  capillary  blood-vesels,  resulting  in  complete  stasis  and  death  of  the 
tissues  involved.  All  conditions  which  impair  cell-nutrition  favor  the 
suppurative  process.  (Senn.)  Death  of  the  tissues  is  not  always 
necessary  to  produce  suppuration,  but  the  changes  which  take  place  in 
the  affected  parts  are  those  which  are  expected  to  follow  intense  irri- 
tation, viz:  hyperemia,  exudation,  coagulation  of  fibrinous  elements, 
and  partial  stasis. 

Suppuration  produced  by  chemical  pyogenic  substances,  like  me- 
tallic mercury,  turpentine,  concentrated  ammonia,  and  croton  oil  in- 
troduced under  the  skin,  hypodermically — with  strict  antiseptic  pre- 
cautions— produce  a  sterile  aseptic  pus,  which  is  very  different  from 
clinical  pus,  while  the  inflammation  and  suppuration  do  not  follow  the 
progressive  course  of  an  infectious  inflammation. 

In  suppuration  due  to  infectious  inflammations,  the  direct  cause 
which  produces  it  multiplies  in  the  tissues.  Consequently  it  has  a  ten- 
dency to  become  progressive,  while  from  the  pus  which  is  produced 
the  pathogenic  micro-organism — pus-microbe — can  be  cultivated,  and 
if  introduced  into  another  organism,  will  produce  inflammation  and 
suppuration.    (Senn.) 

The  power  of  pyogenic  micro-organisms  to  produce  pus  seems  to 
lie  in  their  ability  to  liquefy  the  fibrinous  exudates;  but  in  order  to  ac- 
complish this  it  is  necessary  that  they  be  present  in  large  numbers.  In 
certain  forms  they  exert  a  chemical  action  which  results  in  the  death  of 
the  tissues. 

Pus. — Pus  is  a  thick,  creamy  liquid  of  specific  gravity  1030,  a  prod- 
uct of  suppuration,  consisting  of  degenerated  leucocytes,  living  and 
dead,  liquor  sanguinis,  granular  detritus  from  broken-down  cellular 
structures,  fat-globules,  and  sometimes  flakes  of  coagulated  fibrin. 
Micro-organisms  are  plentiful.  Those  which  produce  suppuration  are 
the  Staphylococcus  pyogenes  aureus.  Staphylococcus  pyogenes  albus, 
Micrococcus  pyogenes  tenuis,  and  the  Streptococcus  pyogenes.  The 
staphylococci  and  the  streptococci  are  the  most  common  forms  which 
produce  suppuration. 

Varieties  of  Pits. — Thick,  cream-like  pus,  without  odor,  coming 
from  acute  inflammation  in  healthy  subjects,  is  termed  good  or  laudable. 

Thin  reddish  pus,  mixed  with  blood,  comes  from  chronic  ulcers 
and  malignant  disease,  and  is  termed  sanioiis. 

Thin,  watery,  irritating  pus  comes  from  chronic  ulcers,  bone- 
disease,  etc.,  and  is  termed  ichorous. 

A  sanious  pus,  containing  flakes  of  coagulated  fibrin,  coming  from 
chronic  abscesses  associated  with  bone-disease,  is  termed  curdy  or 
cheesy. 


INFLAMMATION. 


57 


Thick,  ropy  pus  comes  from  syphilitic  abscesses,  and  is  termed 
giDiiiny. 

Thin,  watery  pus  coming  from  intlamed  mucous  surfaces,  is 
termed  muco-piis, — mucus  mixed  with  pus.  Sometimes  it  is  very 
ofrensive,  having  an  odor  of  hydrogen  sulfid,  when  retained  in  cavities 
like  the  antrum  of  Highmore,  or  the  frontal  sinus.  The  odor  is  the 
result  of  putrefaction. 

Thin,  watery  pus,  containing  considerable  fibrin,  coming  from 
serous  membranes  like  the  pleura  and  peritoneum,  is  termed  sero-pus. 

When  pus  is  not  discharged  it  may  undergo  disintegration  and  be 
absorbed,  or  its  more  liquid  portions,  together  with  the  surrounding 
affected  tissues,  may  undergo  fatty  degeneration  or  form  a  cheesy 
mass,  which  is  termed  caseation. 

Constitutional  Symptoms  of  Acute  Inflammation. — The  most  com- 
mon constitutional  symptom  of  acute  inflammation  is  fever.  Fever 
may  be  sthenic  or  asthenic  in  form.  Sthenic  fever — sthenic  means 
strength — is  characterized  by  full,  strong,  rapid  pulse,  flushed  face,  in- 
jected conjunctivae,  increased  temperature, — ioo°  to  103°  F., — head- 
ache, lumbar  pains,  troubled  sleep;  special  senses  often  hyperesthetic; 
secretions  diminished;  urine  dark  colored,  irritating,  and  of  high  spe- 
cific gravity;  thirst,  tongue  coated  (white  or  yellowish),  and  bowels 
constipated.  This  form  of  fever  is  characteristic  of  strong  and  robust 
individuals. 

Asthenic  fever — asthenic  means  feeble.  This  form  of  fever  is 
common  in  infants,  old  persons,  and  the  very  feeble.  The  general 
symptoms  are  the  same  as  in  the  sthenic  form,  except  that  in  place  of 
overaction  of  the  circulation  there  is  a  profound  depression,  followed 
by  a  typhoid  condition.  The  pulse  is  feeble.  The  temperature  fluctu- 
ates between  99°,  100°,  to  103°  F.,  or  even  as  high  as  105°.  The 
mental  condition  is  dull  and  torpid,  at  times  delirious.  The  tongue  is 
dry  and  coated,  brown  or  black. 

Predisposing  Causes. — Among  the  most  prominent  of  the  predis- 
posing causes  of  inflammation  may  be  mentioned  that  of  age.  Nutri- 
tional changes  in  growing  children  readily  lead  to  inflammatory  condi- 
tions of  the  mucous  membranes,  and  of  the  bones,  which  are  not 
likely  to  occur  in  the  adult  from  the  same  cause.  In  old  age  there  is  a 
lowering  of  the  vital  powers,  resistance  to  the  encroachment  of  patho- 
genic bacteria  is  less  vigorous,  and  as  a  consequence  many  catarrhal 
affections  are  present  at  this  period.  Certain  morbid  conditions  of  the 
blood  also  predispose  to  inflammatory  conditions,  like  the  presence  of 
an  excess  of  uric  acid,  or  of  sugar.  Individuals  with  the  uric-acid 
diathesis  are  prone  to  rheumatic  and  gouty  affections  and  to  inflam- 
mations of  the  pericementum.  There  is  a  well-known  tendency  in 
individuals  suffering  from  diabetes  to  the  formation  of  carbuncles. 


58  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

The  weakened  condition  of  the  system,  however,  may  be  responsible 
for  this  tendency,  rather  than  the  presence  of  the  sugar.  Infection  also 
more  readily  takes  place  in  anemic  subjects  from  the  injection  of  the 
Pyogenes  aureus,  as  proved  by  Gartner,  thus  explaining  the  reason  for 
the  frequency  of  boils  in  persons  of  debilitated  health.  The  excessive 
use  of  alcoholic  stimulants  is  also  a  predisposing  cause  of  inflammatory 
affections.  Climatic  influences  are  very'  potent  factors  in  predisposing 
to  inflammations, — in  cold  climates  to  afifections  of  the  throat  and 
lungs,  in  hot  climates  to  affections  of  the  abdominal  viscera. 

Symptoms  and  Diagnosis. — The  diagnosis  of  a  typical  case  of 
acute  inflammation  occurring  upon  the  surface  of  the  body,  with  all 
the  symptoms  well  marked,  would  be  an  easy  matter  to  any  one  of  lim- 
ited experience.  The  local  symptoms  of  redness,  heat,  swelling,  and 
pain  are  always  present  in  a  typical  acute  inflammation,  while  the  con- 
stitutional symptoms  of  elevation  of  temperature,  etc.,  are  more  or  less 
marked.  Its  character,  course,  and  termination  will  depend  upon  the 
primary  cause  of  the  affection,  the  condition  of  the  patient,  and  the 
environment.  According  to  Senn,  the  nature  of  the  primary  cause 
determines  the  character  and  course  of  the  inflammation.  The  mi- 
crobes of  suppuration,  erysipelas,  anthrax,  glanders,  tetanus,  and  gon- 
orrhea cause  acute  affections,  vvhile  the  micro-organisms  of  tuber- 
culosis, lepra,  and  actinomycosis  cause  affections  which  are  marked  by 
the  chronicity  of  their  course  and  development. 

Acute  inflammation  may  become  subacute,  and  finally  chronic. 
Dental  pulpitis  and  pericementitis  occasionally  pass  through  all  three 
of  these  stages.  In  acute  inflammations,  where  the  diagnosis  is  clear, 
it  only  remains  to  decide  upon  the  character  of  the  infection. 

The  fever  which  attends  the  inflammation  is  only  a  symptom,  and 
is  indicative  of  the  introduction  into  the  system  of  poisonous  sub- 
stances resulting  from  the  pathologic  changes  which  have  taken  place 
in  the  exudates  or  the  fixed  tissue-cells,  by  reason  of  the  action  of 
specific  micro-organisms.  The  micro-organisms  which  produce  acute 
inflammation  differ  very  greatly  in  their  power  to  cause  elevation  of 
temperature  from  the  substance  which  they  produce  in  the  inflamed 
tissues.  The  changes  in  the  tissues  caused  by  the  Micrococcus 
pyogenes  tenuis  of  suppuration  do  not  produce  so  high  a  temperature 
as  when  caused  by  the  Staphylococcus  pyogenes  aureus  or  albus,  or 
the  Streptococcus  pyogenes.     (Senn.) 

The  general  disturbances,  such  as  headache,  lumbar  pains,  loss  of 
appetite,  vomiting,  constipation,  feeling  of  lassitude,  etc.,  which  attend 
acute  inflammations,  are  caused  by  the  elevated  temperature,  and  the 
presence  of  specific  ptomaines  in  the  blood. 

Just  how  micro-organisms  cause  febrile  irritations,  whether  by  the 
production  of  chemical  substances  which  enter  the  blood  by  absorp- 


INFLAMMATION.  59 

tion,  or  by  their  simple  presence  in  the  tissues,  cannot  be  definitely 
stated.  It  is  a  well-known  fact,  however,  that  many  surgical  fevers  are 
due  to  the  presence  in  the  blood  and  tissues  of  a  ptomaine  produced  by 
chemical  changes  occurring  in  putrefying  wounds  in  the  presence  of 
micro-organisms.  Febrile  disturbance  following  injury  is  not  always 
dependent  upon  the  presence  of  bacteria.  Genuine  fever  may  develop 
in  cases  where  perfect  asepsis  has  been  secured,  and  the  wounds  have 
healed  by  first  intention.  Simple  fractures  and  other  subcutaneous 
injuries  are  often  followed  by  elevation  of  temperature,  probably  the 
result  of  shock.  Warren  says,  "In  general  it  may  be  said  fever  is  due 
to  the  presence  in  the  blood  of  a  pyogenous  substance  of  an  organic 
nature,  that  may  have  been  produced  by  bacteria,  or  have  been  due  to 
the  presence  of  bacteria,  or  finally,  to  some  ferment-like  substance 
which  has  resulted  from  cell-disintegration;"  while  Senn  says,  "The 
nature  of  the  inflammatory  product  always  answers  to  the  specific 
action  of  the  microbe." 

The  inflammation  caused  by  pus-microbes  results  in  the  formation 
of  pus,  while  the  microbes  which  cause  chronic  inflammation  as  a  rule 
only  convert  the  pre-existing  mature  tissue  by  degenerative  meta- 
morphosis into  an  embryonal  form,  a  granulation-tissue.  Those 
micro-organisms  whose  existence  in  the  tissues  is  short-lived,  as  for 
instance  the  streptococcus  of  erysipelas,  may  give  rise  only  to  an 
intense  hyperemia,  wdth  moderate  exudation  and  migration  of  the 
blood-corpuscles.  Genuine  uncomplicated  erysipelas  is  of  such  short 
duration  that  the  inflammatory  symptoms  rapidly  subside,  and  perfect 
restoration  of  the  parts  is  accomplished  in  a  few  days. 

Prognosis. — Resolution  is  the  most  favorable  termination  of  in- 
flammation. The  inflammatory  process  is  arrested  "as  soon  as  the 
blood  which  circulates  through  the  vessels  restores  their  walls  to  a 
normal  condition."  When  this  condition  is  brought  about,  resolution 
is  immediately  established.  The  exudation  ceases  as  soon  as  the 
vessels  are  restored  to  functional  activity,  and  the  process  of  resorption 
of  the  exuded  plasma  and  leucocytes  begins  immediately.  The  simple 
serous  exudates  are  those  which  are  most  readily  resorbed.  As  soon  as 
the  normal  nutrition  of  the  part  is  readjusted,  the  constituent  cells  of 
the  tissues  which  have  been  injured  in  the  course  of  the  inflammation 
take  on  new  vigor,  and  soon  recover  their  normal  condition. 

Resolution  is  only  possible  in  the  milder  forms  of  inflammation, 
where  the  migration  of  the  leucocytes  has  been  moderate  in  quantity, 
and  where  the  exudates  and  the  cellular  elements  have  not  been  con- 
verted into  pus-corpuscles.  In  resolution,  many  of  the  escaped  leuco- 
cytes which'  have  retained  their  vitality  return  through  the  vessel-walls 
into  the  general  circulation,  or  through  the  lymphatic  system.  The 
blood-corpuscles  which  remain,  both  white  and  red,  undergo  degen- 


6o  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

eration  and  liquefaction,  and  are  removed  by  absorption.  The  coagu- 
lated fibrin  of  the  exudates  is  transformed  into  a  granular  mass,  and  is 
then  removed  in  like  manner.  The  embryonal  cells  which  have  lost 
their  vitality  by  reason  of  the  inflammation  are  also  converted  into 
granular  masses,  and  absorbed. 

The  loss  of  tissue  caused  by  the  inflammation,  if  not  too  extensive, 
and  if  the  remaining  parts  are  healthy,  will  soon  be  replaced  by  the 
process  of  regeneration,  accomplished  through  the  karyokinetic  func- 
tion of  the  fixed  tissue-cells.  The  epithelial  cells  produce  epithelium, 
the  muscle-cells  generate  new  muscular  tissue,  the  periosteum  forms 
new  bone,  the  fibroblasts  new  fibrous  tissue,  new  blood-vessels  are 
formed  by  capillary  offshoots  from  existing  vessels,  and  new  nerves 
from  nerve-cells,  etc. 

Inflammatory  exudates  become  a  source  of  danger,  when,  by 
reason  of  their  amount,  they  cause  mechanical  pressure  that  interferes 
with  the  performance  of  function  in  important  organs,  like  the  heart, 
the  lungs,  or  the  brain.  (Senn.)  A  moderate  amount  of  inflammatory 
exudation  occurring  in  any  of  the  meninges  of  the  brain  may  cause 
death  from  compression.  Effusion  into  the  pericardium  of  sufficient 
quantity  to  interfere  with  the  action  of  the  heart  would  cause  death  by 
syncope.  A  copious  efifusion  into  the  pleural  cavity,  especially  if  it 
accumulates  rapidly,  may  so  interfere  with  respiration  as  to  cause 
death  by  apncea,  while  a  slight  edema  of  the  glottis  or  diphtheritic 
exudation  upon  the  vocal  cords  may  destroy  life  by  causing  mechan- 
ical obstruction  to  the  entrance  of  sufficient  air  to  the  lungs. 

The  modifying  influences  which  control  the  effects  of  inflamma- 
tion are  the  age  and  general  condition  of  the  individual.  Infants  and 
elderly  persons  have  little  resistive  power;  consequently,  when  at- 
tacked with  inflammation,  the  disease  is  prone  to  lead  to  serious 
results.  The  same  is  true  of  persons  debilitated  from  disease  or  ex- 
cesses, particularly  intemperance  in  the  use  of  alcoholic  drinks. 

In  tuberculosis  there  is  always  danger  of  extension  of  the  disease 
to  other  organs  through  the  specific  bacilli  which  are  carried  by  the 
circulation  and  lymphatic  channels. 

"Chronic  suppuration  eventually  causes  amyloid  degeneration  of 
the  important  organs,  and  death  ensues  as  a  result."     (Senn.) 


CHAPTER   V. 
TREATMENT    OF   INFLAMMATION. 

Sexx  says.  Inflammation  is  not  a  disease,  but  a  symptom;  an 
effort  upon  the  part  of  the  system  to  eliminate,  or  render  inert  or 
harmless  the  primary  cause ;  the  treatment,  therefore,  must  be  directed 
in  each  individual  case  to  the  symptoms  presented. 

The  nature  and  tendencies  of  inflammation  must  be  thoroughly 
understood  in  order  to  arrive  at  a  rational  method  of  treatment. 

A'an  Buren  defines  inflammation  as  "a  condition  located  in  the 
apparatus  of  nutrition,  affecting  a  limited  area,  and  consisting  in  tem- 
porary perversion  of  nutrition  from  its  natural  and  regular  order." 

The  treatment  of  septic  inflammation,  as  of  all  other  affections, 
comprehends  the  questions  of  prevention  and  cure.  The  subject  may 
therefore  be  divided  into  Prophylactic  trcatinoit  and  Curative  treatment. 

Prophylactic  treatment  is  of  first  and  greatest  importance,  and  the 
old  adage  that  ''an  ounce  of  prevention  is  worth  a  pound  of  cure'"  never 
had  greater  force,  nor  was  ever  more  strongly  indorsed  or  more  firmly 
believed  by  the  profession  and  the  general  public  than  it  is  to-day.  The 
evidence  of  this  is  constantly  before  us  in  the  efforts  of  medical  and 
surgical  science  to  discover  means  for  rendering  the  animal  economy 
immune  to  disease,  and  of  methods  of  combating  the  spread  of  con- 
tagious and  epidemic  diseases.  At  no  time  in  the  history  of  the  world 
has  such  great  advancement  been  made  in  this  direction  as  during  the 
last  decade.  The  study  of  the  science  of  bacteriology  has  done  more  to 
awaken  interest  and  stir  enthusiasm  in  the  subject  of  preventive  medi- 
cine than  all  other  subjects  combined;  in  fact,  it  is  the  key  to  the  whole 
situation. 

Prophylactic  treatment  in  acute  septic  inflammation  by  antiseptic 
methods  is  of  first  importance,  and  is  usually  yery  satisfactory  in  its 
results.  Preventive  antiseptic  precautions  have  made  modern  surgery 
what  it  is  to-day.  The  surgeon  or  the  dentist  who  fails  to  properly 
appreciate  the  value  of  prophylactic  treatment  from  the  standpoint  of 
antisepsis  is  behind  his  day  and  generation,  and  cannot  hope  for  the 
same  degree  of  success  in  the  prevention  and  cure  of  disease  as  those 
who  follow  the  antiseptic  method.  The  specific  action  of  the  pus- 
microbes  is  no  longer  doubted  by  even  the  most  skeptical. 

6i 


62  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

Lister,  the  apostle  of  antiseptic  surgery,  and  his  early  disciples,  by 
their  work  and  teaching,  have  been  the  means  of  saving  thousands 
upon  thousands  of  human  lives  that  otherwise  would  have  been  lost. 

The  mortality  of  even  the  most  desperate  operations,  when  anti- 
septic methods  can  be  used,  has  been  so  reduced  that  many  have  been 
encouraged  to  suggest  and  to  attempt  operations  which  at  any  previ- 
ous time  would  have  been  considered  the  vaporings  of  a  diseased  mind 
(Senn),  or  stigmatized  as  criminal. 

The  abdominal  cavity  is  now  opened  with  impunity,  and  operations 
made  upon  the  inclosed  viscera  that  a  few  years  ago  would  have  been 
considered  impossible.  The  chest  is  explored,  and  portions  of  the  lung 
removed.  The  cranium  is  perforated,  and  tumors  extracted  from 
portions  of  the  brain,  and  a  large  percentage  of  the  individuals  op- 
erated upon  recover,  and  are  restored  to  health  and  usefulness. 

By  the  introduction  of  antisepsis  the  surgeon  has  it  in  his  power 
to  prevent  the  almost  innumerable  complications  surrounding  trau- 
matic injuries,  and  their  too  often  fatal  terminations. 

The  preventive  treatment  of  inflammation  in  relation  to  wounds 
and  other  avenues  of  infection,  consists  in  so  protecting  the  locality 
which  has  been  deprived  of  its  natural  barrier  against  the  entrance  of 
pathogenic  micro-organisms — the  skin  and  mucous  membrane — by 
first  securing  an  aseptic  condition  of  the  parts,  and  maintaining  this 
by  bringing  in  contact  with  it  only  such  things  as  are  in  themselves 
antiseptic,  or  as  have  been  rendered  aseptic  by  thorough  sterilization. 
In  inflammations  where  there  is  no  external  traumatism  through  which 
infection  could  have  entered,  it  must  be  taken  for  granted  that  the 
micro-organisms  have  found  ingress  to  the  circulation  through  some 
slight  break  in  the  continuity  of  the  external  tissues,  which  has  left  no 
mark,  and  has  escaped  the  notice  of  the  patient;  or  the  infection  may 
have  entered  through  some  of  the  various  appendages  of  the  skin  or 
mucous  membrane,  and  later  located  in  some  organ  or  part  which  by 
its  abnormal  condition  is  prepared  to  foster  their  growth,  a  location 
which  has  at  the  time  a  lowered  vital  resistive  power.     (Senn.) 

Prevent  the  infection  of  a  wound  by  pus-forming  microbes,  and 
inflammation  is  prevented.  Both  in  theory  and  clinical  experience 
this  axiom  is  eminently  true. 

Curative  Treatment. — It  has  already  been  intimated  that  irritation 
and  inflammation  sustain  to  each  other  the  relationship  of  cause  and 
effect.  It  is  therefore  readily  seen  that  curative  treatment,  to  be  effec- 
tive, must  reach  beyond  the  use  of  palliative  measures,  and  destroy, 
eliminate,  or  render  inert  the  active  or  exciting  cause,  by  means 
adapted  to  the  nature,  course,  and  progress  of  the  inflammation  and 
the  condition  of  the  patient.  These  methods  may  be  radical  or  con- 
servative, but  in  either  case  they  should  be  directed  to  the  removal  of 


TREATMENT    OF    INFLAMMATION.  63 

the  cause  of  irritation  at  the  earliest  practicable  moment,  compatible 
with  the  surrounding-  conditions.  When  the  disturbing-  cause  is  purely 
local  its  removal  may  sometimes  be  easily  accomplished  by  resorting 
to  a  surgical  operation,  as,  for  instance,  the  removal  of  a  fragment  of 
bone,  splinters,  bullets,  or  other  foreign  substances;  the  resection  of 
diseased  joints  (Senn),  the  extraction  of  diseased  teeth,  the  evacuation 
of  pent-up  secretions,  releasing  strangulated  tissues,  rendering  innoc- 
uous infective  or  acrid  discharges,  or  promptly  displacing  the  contents 
of  abscesses,  and  establishing  drainage  to  prevent  further  accumu- 
lation. 

Local  Treatment. — Senn  says,  recognizing  the  fact  that  acute  in- 
flammation, wherever  it  occurs,  is  the  result  of  the  action  of  certain 
specific  micro-organisms  upon  the  vessel-walls  and  the  tissues  outside 
of  them,  the  rational  treatment  would  seem  to  be  to  destroy  the 
microbes  in  the  tissues  as  soon  as  their  presence  is  discovered,  by 
the  saturation  of  the  tissues  with  some  solution  having  germicidal 
powers. 

Heuter  advised  and  extensively  practiced  this  method  long  before 
it  was  known  that  certain  microbes  and  definite  forms  of  inflammation 
had  any  relationship  with  one  another.  He  also  claimed  that  all  inflam- 
mations were  caused  by  certain  noxse  (harmful,  hurtful,  baneful  sub- 
stances) introduced  from  without  the  body,  and  which  he  tried  to 
combat  by  saturating  the  tissues  with  antiseptic  solutions.  His 
favorite  remedy  was  a  3  tq  5  per  cent,  solution  of  carbolic  acid.  This 
he  introduced  into  the  tissues  by  means  of  a  Pravaz  syringe,  armed 
with  a  long  needle  having  several  lateral  openings. 

In  adults  he  often  injected  as  much  as  ten  grammes.  In  treating 
large,  open,  granulating  surfaces,  or  tubercular  foci,  he  used  an  infuser 
in  place  of  the  syringe.  This  was  a  graduated  glass  cylinder,  having  a 
rubber  tube  attached,  and  this  joined  to  the  needle;  and  he  depended 
upon  gravitation  to  diffuse  the  solution  through  the  soft  granular 
tissue.  This  method  has  never  been  generally  practiced,  for  the  reason 
that  except  in  inflammatory  conditions  of  very  limited  area,  there 
would  be  too  great  danger  of  causing  the  death  of  the  patient  by  a  toxic 
dose  of  the  germicidal  agent. 

Corrosive  sublimate,  permanganate  of  potassa,  nitrate  of  silver, 
iodin,  and  other  germicidal  agents,  have  all  been  used  in  the  same 
way,  but  with  no  degree  of  satisfaction. 

■  If  this  method  is  practiced,  it  should  be  under  strict  antiseptic 
precautions,  the  amount  of  the  agent  introduced  should  never  exceed 
the  dose  given  internally,  and  the  danger  from  a  toxic  dose  should  be 
remembered  if  the  injection  is  repeated. 

Depletion. — For  generations  it  has  been  the  practice  to  deplete  the 
system  by  venesection,  and  the  internal  use  of  emetics  and  cathartics, 


64  SURGERY    OF    THE    FACE,    MOUTH,    AND   JAWS. 

to  reduce  the  arterial  tension  in  inflammation,  and  thereby  prevent,  or 
cut  short,  the  more  serious  symptoms.  Blood-letting  is  rarely  ever 
resorted  to  in  these  .days  in  the  treatment  of  any  form  of  inflammation. 
General  depletion,  if  carried  far  enough  to  weaken  the  vital  forces, 
diminishes  the  prospect  of  a  favorable  termination  of  the  inflammation. 
General  depletion  favors  stasis;  local  depletion  often  proves  of  great 
value  by  relieving  the  engorged  capillary  vessels,  and  thereby  prevent- 
ing stasis. 

Leeches  should  never  be  used,  as  they  often  carry  infection  which 
may  prove  disastrous.  Scarification,  as  generally  practiced  for  cup- 
ping, is  unsafe,  for  the  reason  that  it  is  difificult  to  keep  the  instruments 
aseptic,  and  the  number  and  depth  of  the  incisions  are  not  under  the 
control  of  the  surgeon. 

Local  depletion  is  best  obtained  by  incisions  made  with  a  scalpel, 
and  free  bleeding  promoted  by  the  use  of  warm  water. 

Vomiting  and  diarrhea  sometimes  occur  in  the  early  stages  of 
acute  inflammation.  This  is  an  attempt  upon  the  part  of  the  system  to 
eliminate  through  the  gastro-intestinal  mucous  membrane  the  toxic 
elements  which  have  been  introduced  into  the  circulation  by  the 
presence  of  the  micro-organisms. 

This  process  of  elimination  can  be  promoted  by  administering  a 
few  doses  of  hydrargyri  chloridum  mite,  followed  by  a  saline  cathartic, 
and  will  also  many  times  control  the  vomiting  and  diarrhea  more 
promptly  than  the  remedies  usually  administered   for  that  purpose. 

Rest. — Rest  of  an  inflamed  organ  or  part  is  one  of  the  most  valu- 
able adjuncts  to  the  methods  of  treatment,  and  should  approach,  as 
nearly  as  possible,  physiological  rest.  Examples,  the  exclusion  of 
light  from  an  inflamed  eye;  fixation  of  a  limb  with  inflamed  joint;  pre- 
vention of  occlusion  of  a  tooth  that  has  become  sore  from  pericemen- 
titis; interdiction  of  the  use  of  the  voice  in  inflammatory  conditions  of 
the  tonsils,  pharynx,  or  larynx.  (Senn.)  Such  rest  often  affords 
marked  relief  from  the  severity  of  the  pain. 

The  advantages  of  elevation  of  an  inflamed  part  cannot  be  over- 
estimated, and  are  most  manifest  in  inflammatory  affections  of  the 
extremities.  The  throbbing  pain  is  greatly  aggravated  when  the  limb 
is  kept  in  a  dependent  position.  Elevation  not  only  relieves  the  pain, 
but  greatly  assists  in  removing  the  edematous  condition.  It  is  often 
necessary  to  secure  complete  rest  of  the  entire  body  in  severe  cases  of 
acute  inflammation.  The  recumbent  position  is  usually  the  best;  this 
relieves  arterial  tension,  prevents  unnecessary  strain  upon  the  blood- 
vessels, and  rediices  the  dangers  of  embolism  from  the  detachment  of 
a  thrombus.  Persons  suffering  from  alveolar  abscesses  and  pulpitis 
find  a  sitting  or  recumbent  position  most  comfortable ;  exercise  in  any 
form  increases  the  pain  by  increasing  arterial  tension. 


TREATMENT    OF    INFLAMMATION.  65 

Cold. — Senn  believes  the  application  of  cold  has  been  resorted  to 
indiscriminately  in  the  treatment  of  inflammation.  No  agent  is  more 
potent  for  good  or  harm,  according  to  the  stage  of  the  inflammatory 
process  to  which  it  is  applied.  In  the  early  Stages  of  inflammation, 
before  exudation  has  progressed  beyond  its  first  beginnings,  and  the 
capillary  vessels  are  dilated  and  only  partially  obstructed,  it  is  of  great 
advantage  by  producing  contraction  of  the  blood-vessels,  and  retard- 
ing the  growth  and  multiplication  of  the  micro-organisms. 

If  stasis  has  become  established,  the  application  of  cold  will  prove 
harmful,  by  preventing  the  establishment  of  collateral  circulation,  and 
increasing  the  dangers  of  complete  stasis  and  death  of  the  part. 

Cold  is  most  effective  in  a  superficial  inflammation,  but  often 
proves  of  benefit  in  inflammations  of  the  deeper  structures  when  its 
use  is  prolonged.  (Examples,  the  pleura,  peritoneum,  bones,  joints, 
teeth,  and  the  meninges  of  the  brain.) 

The  best  method  of  applying  cold  is  by  means  of  the  ice-bag,  the 
part  being  protected  from  the  danger  of  freezing  by  being  covered 
with  a  wet  towel,  folded  several  times.  It  is  most  beneficial  in  those 
cases  in  which  congestion  of  the  vessels  is  a  prominent  symptom,  and 
where  redness  and  heat  are  pronounced.     (Warren.) 

Heat. — Heat  is  most  beneficial  in  the  later  stages  of  inflammation, 
and  is  best  applied  by  means  of  compresses  wrung  out  of  hot  antiseptic 
solutions,  covered  with  rubber  sheeting,  and  reapplied  as  often  as 
they  become  cooled.  Hot  fomentations  favor  collateral  circulation^ 
stimulate  the  absorption  of  the  exudates,  and  relieve  the  pain.  The 
surface  to  which  the  fomentations  are  to  be  applied  should  be  thor- 
oughly cleansed  with  soap  and  water. 

Care  must  be  exercised  in  the  selection  of  the  antiseptic  drug; 
the  age  and  condition  of  the  patient,  and  the  area  to  be  covered,  must 
be  taken  into  consideration,  to  avoid  producing  toxic  symptoms. 
Carbolic  acid  and  sublimate  solutions  must  be  used  with  care  with  aged 
persons  and  little  children,  or  with  persons  suffering  from  affections 
of  the  kidneys.  A  i  per  cent,  solution  of  acetate  of  aluminum,  a  satu- 
rated solution  of  boric  acid,  or  the  Thiersch  solutions,  are  entirely  safe, 
and  quite  as  efficacious  as  the  more  poisonous  drugs.  All  antiseptic 
solutions  should  be  made  from  sterilized  water. 

Senn  thinks  poultices  of  every  name  and  nature  should  be  rele- 
gated to  the  dead  past,  and  never  used  by  any  enlightened  surgeon,  as 
they  are  simply  hotbeds  of  pollution  and  infection. 

Warren  says  heat  acts  differently  according  to  the  degree  used. 
Mild  heat  favors  an  increase  of  hyperemia;  greater  heat  causes  con- 
striction of  the  blood-vessels. 

Constitutional  Treatment. — Drugs  are  of  little  value  for  reducing 
the  temperature  in  inflammation.     The  coal-tar  derivatives,  salicylate 

6 


66  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

of  soda,  salol,  quinin,  and  other  antipyretics,  when  employed  in  large 
doses  to  reduce  the  temperature,  accomplish  this  result  at  the  expense 
of  the  vital  forces,  which  are  already  being  taxed  very  greatly  in  the 
effort  to  eliminate  the  poisonous  elements  which  have  been  introduced 
by  the  action  of  the  micro-organisms. 

Sponging  the  surface  of  the  body  with  tepid  water,  or  the  use  of 
warm  baths,  is  far  more  effective  in  reducing  the  temperature;  and 
besides  being  grateful  to  the  patient,  promotes  elimination,  and  the 
dangers  from  disarranging  the  stomach  and  weakening  the  heart  by 
large  doses  of  antipyretics  are  obviated. 

Cathartics  are  very  valuable  in  many  cases,  and  have  probably  a 
wider  range  of  usefulness  in  inflammation  than  any  other  class  of  con- 
stitutional remedies.  Their  chief  value  lies  first  in  removing  the 
unwholesome  ingesta  and  acrid  fecal  accumulations  from  the  stomach 
and  bowels.  Second,  by  stimulating  the  secretions  of  the  gastric  and 
intestinal  glands,  the  liver,  the  pancreas,  etc.,  they  assist  the  system  to 
eliminate  through  these  channels  the  toxic  elements  which  have  been 
introduced  into  the  blood  by  the  presence  of  micro-organisms.  Third, 
by  their  revulsive  action,  which,  operating  upon  such  an  extensive 
surface  in  immediate  sympathy  with  the  whole  nervous  system,  exerts 
a  powerful  influence  in  withdrawing  nervous  action,  or  over-action, 
from  the  inflamed  part. 

Diaphoretics  and  diuretics  are  both  valuable  aids  to  other  means 
of  treatment,  as  they  promote  elimination  of  toxic  substances.  The 
kidneys  are  avenues  through  which  are  eliminated  micro-organisms 
that  reach  them  through  the  general  circulation. 

The  development  of  symptoms  of  sepsis  in  the  course  of  an  inflam- 
mation calls  for  the  administration  of  diffusible  stimulants,  which 
should  be  used  freely  to  ward  off  the  dangers  from  approaching  heart- 
failure.     Brandy,  cognac,  and  whiskey  are  the  best  for  the  purpose. 

Diet. — The  diet  should  be  nutritious,  and  well  selected;  meat- 
broths,  beef-tea,  and  milk  should  be  given  freely  from  the  beginning, 
'  and  if  the  stomach  will  bear  it,  more  substantial  food.  The  days  of 
starvation  treatment  have  passed  away,  and  the  aim  of  the  surgeon  to- 
day is  to  sustain  the  vital  powers  of  the  patient,  that  he  may  make  a 
more  successful  fight  against  disease.  If  the  stomach  will  not  retain 
food,  then  the  strength  of  the  individual  must  be  sustained  by  nutritive 
rectal  enemata  of  peptonized  milk  and  beef-tea,  in  quantities  of  two  to 
four  ounces,  alternately,  every  six  to  eight  hours,  as  the  condition  of 
the  patient  suggests.  Tonic  doses  of  quinin  are  sometimes  indicated 
where  the  inflammatory  symptoms  are  protracted.  When  the  appetite 
is  defective,  some  of  the  bitter  tonics  will  be  found  useful,  and  after 
the  acute  symptoms  have  subsided,  the  tincture  of  chlorid  of  iron  will 
be  found  of  great  advantage. 


TREATMENT    OF    INFLAMMATION.  67 

To  relieve  pain,  chloral  and  phenacetin  are  to  be  preferred  to 
opium.  There  is  great  danger  in  painful  chronic  conditions  of 
forming  the  habit  of  taking  anodynes.  Caution  should  therefore  be 
exercised,  and  it  would  be  better  to  seek  for  the  cause  of  the  pain,  and 
remove  it  by  local  measures,  if  possible,  than  to  depend  upon  drugs  to 
give  relief. 


CHAPTER   VI. 
CHRONIC  INFLAMMATION. 

Chronic  Inflammation  is  generally  preceded  by  the  acute  form, 
which  has  not  passed  beyond  the  stages  of  partial  stasis  and  suppura- 
tion, or  of  ulceration. 

Its  Causes  are  long-continued  local  irritation,  or  functional  activ- 
ity, constitutional  dyscrasia,  or  diathesis. 

Its  most  common  terminations  are  Induration,  Hypertrophy, 
Tumefaction,  Suppuration,  Ulceration,  and  Fatty  Degeneration  of  the 
infiltrated  tissues,  the  formation  of  cold  abscesses  from  the  breaking 
down  of  this  degenerative  tissue,  and  Caseation. 

Induration  (Lat.  induro,  1  harden).  A  process  of  hardening  the 
tissues  from  coagulation  of  the  fibrinous  elements  of  the  exudates,  and 
new^-formations  in  the  connective  tissues. 

Hypertrophy  (Lat.  hyper,  excess;  Gr.  rfjo<fr^,  nourishment). 
Enlargement  of  a  part  due  to  constant  irritation  and  congestion,  re- 
sulting in  the  formation  of  new  tissue  elements  of  the  same  character. 

Tumefaction  (Lat.  tiimere,  to  swell,  facere,  to  make)  (a  tumor, 
a  swelling).  A  circumscribed  enlargement,  caused  by  proliferation 
of  cells  and  their  organization  into  new  tissue,  often  of  a  different 
character,  resulting  in  the  formation  of  tumors  of  various  kinds, 
benign  and  malignant. 

Fatty  Degeneration.  A  process  or  retrograde  change,  by  which 
the  albuminoid  elements  of  the  tissues  and  the  exudates  are  con- 
verted into  granular  fatty  matter. 

Caseation  is  a  process  of  degeneration  in  pus,  tubercles,  etc..  by 
which  they  are  converted  into  a  soft,  cheese-like  mass. 

The  presence  of  chronic  inflammation  implies  either  a  continued 
existence  of  the  original  cause,  some  abnormal  condition  of  the  general 
system,  or  both.  Councilman  thinks  "the  condition  of  the  individual 
has  often  much  to  do  with  the  chronicity  of  inflammation."  A  feeble 
condition  of  the  circulation  results  in  a  tardy  and  incomplete  resorp- 
tion of  the  exudates. 

The  local  manifestations  of  chronic  inflammation  differ  from  the 
acute  form  only  in  the  degree  of  severity.     The  cardinal  symptoms  are 
all  less  marked,  or  may  be  so  slight  as  to  escape  notice  altogether. 
68 


CHRONIC    INFLAMMATION.  •       69 

The  vascular  changes  in  the  tissues  which  have  been  already  de- 
scribed come  on  more  slowly,  and  never  assume  the  degree  of  severity 
which  is  characteristic  of  the  acute  form,  and  for  this  reason  the  migra- 
tion of  the  leucocytes  takes  place  much  less  rapidly,  and  in  some 
instances  does  not  occur  at  all. 

According  to  Senn,  the  inflammatory  product  is  composed  largely 
of  efifused  plastic  lymph,  which  undergoes  partial  organization  and 
causes  induration,  and  of  embryonal  cells  derived  from  the  fixed  tissue- 
cell.  Sometimes  the  inflammatory  product  is  largely  or  entirely  com- 
posed of  these  embryonal  cells.  This  is  explained  by  the  action  of  the 
noxious  elements  which  cause  chronic  inflammation  exerting  their 
baneful  effects  more  directly  upon  the  tissue-cells  than  upon  the  capil- 
lary blood-vessels. 

The  efifect  upon  the  tissues  is  to  convert  the  mature  tissue-cells 
into  an  embryonal  form,  and  to  increase  their  proliferation,  thus  form- 
ing granulation-tissue  which  remains  in  this  condition  so  long  as  the 
primary  cause  of  the  inflammation  retains  its  pathogenic  qualities,  or 
until  degenerative  changes  take  place  in  the  new  cells.  Warren  says, 
"If  the  exudation  goes  on  to  such  an  extent  that  the  part  is  completely 
infiltrated  with  leucocytes,  the  structure  of  the  tissue  will  be  seriously 
impaired  and  the  fibers  and  cells  of  the  part  disappear.  The  fixed 
cells  undergo  proliferation  and  become  indistinguishable  from  the 
migratory  cells,  the  intercellular  substance  is  gradually  changed  into  a 
more  or  less  homogeneous  granular  material  in  which  the  new  cells 
are  imbedded,  which  constitutes  granulation-tissue."  The  degenera- 
tive change  which  most  frequently  takes  place  in  this  temporary  tissue 
is  fatty  degeneration,  and  this  may  break  down  and  liquefy,  forming 
cold  abscesses. 

If  degenerative  changes  do  not  take  place  in  the  embryonal  cells, 
and  the  primary  cause  ceases  to  exist,  the  new  cells  are  either  resorbed 
or  converted  into  mature  tissue,  and  the  inflammation  results  in 
a  hyperplasia  of  tissue. 

Chronic  inflammation  includes  all  that  class  of  affections  known  as 
"inflammatory  swellings,"  or  granulomata.  All  of  the  inflammatory 
swellings  are  composed  of  granulation-tissue  irrespective  of  the  nature 
of  the  primary  cause.  The  granulomata  have  been  classed  by  some 
eminent  pathologists  with  the  neoplasms  or  tumors,  because  their 
development  is  usually  attended  with  none  of  the  characteristic  symp- 
toms of  inflammation;  and  on  account  of  their  tendency  to  spread  to 
adjacent  tissues  and  involve  remote  parts  by  dissemination  through 
the  lymphatic  system,  they  have  a  close  resemblance  to  the  malignant 
growths. 

The  granulomata  are  true  inflammatory  products. 

Under  the  microscope  they  exhibit  all  the  characteristic  appear- 


yO  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

ances  of  inflammation,  and  histologically  are  composed  of  embryonal 
cells,  representing  the  type  of  tissue  from  which  they  had  their  origin. 

Tuberculosis,  syphilis,  and  actinomycosis  are  examples  of  inflam- 
matory swellings  or  granulomata. 

Treatment. — Local  treatment  in  chronic  inflammation  would  be  the 
same  as  that  followed  in  the  acute  form  of  the  affection,  as  far  as  the 
removal  of  the  cause  is  concerned,  the  same  means  being  used  in  both. 
Another  method  of  treatment  sometimes  resorted  to  by  surgeons  is  to 
convert  a  chronic  inflammation  into  the  acute  form  of  the  affection, 
as  this  is  nature's  way  of  establishing  a  cure.  This  may  be  accom- 
plished by  various  drugs,  such  as  iodin,  nitrate  of  silver,  etc.,  or  the 
actual  cautery  or  the  electro-thermal  cautery. 

Stimulating  applications  like  the  ammonia  liniment,  tincture  of 
iodin,  etc.,  are  useful  as  aids  in  promoting  resorption.  Counter-irri- 
tants are  sometimes  serviceable,  but  if  applied  indiscriminately  are 
likely  to  do  more  harm  than  good. 

Massage  is  an  exceedingly  important  and  efficient  means  of  treat- 
ment in  chronic  inflammatory  affections,  when  scientifically  practiced. 
Its  value  lies  in  the  fact  that  it  stimulates  the  vessels  to  increased  action, 
assists  in  restoring  a  normal  circulation  through  the  injured  capillaries, 
and  greatly  promotes  the  process  of  resorption. 

The  application  of  hot  and  cold  douches,  rest,  active  or  passive 
movements,  etc.,  adapted  to  the  individual  case,  will  often  prove  of 
great  benefit  and  materially  hasten  a  cure. 

Constitutional  treatment  is  of  the  utmost  importance  in  many  forms 
of  chronic  inflammation,  from  the  fact  that  there  is  associated  with  the 
local  condition  a  constitutional  or  systemic  dyscrasia,  often  more 
alarming  than  the  local  manifestation. 

Fortunately,  however,  many  of  these  cases,  though  they  differ 
widely  as  to  the  pathologic  characters  of  the  systemic  dyscrasia,  may 
be  classified  clinically  as  examples  of  enfeebled  constitutions,  and  as 
demanding  nutritious  food,  tonics,  and  perhaps  stimulants.  (Ham- 
ilton.) Such  cases  are  greatly  benefited  by  improved  hygienic  sur- 
roundings, fresh  air,  sunlight,  exercise,  nutritious  food,  tonics,  etc., 
a  sea  voyage,  a  trip  to  the  mountains  or  the  seashore. 

In  tubercular  inflammation  cod-liver  oil  and  iodin  are  demanded. 
In  syphilitic  inflammations,  represented  by  the  gummata,  vigorous 
antisyphilitic  treatment  soon  causes  the  local  lesion  to  disappear,  and 
greatly  improves  the  general  health. 

The  other  specific  causes  of  general  enfeebled  health  are  diseases 
of  the  digestive  organs,  the  liver  and  the  kidneys,  the  rheumatic  and 
gouty  diathesis,  septicemia,  pyemia,  or  other  blood-poisoning.  These 
conditions  must  be  combated  and  the  general  health  improved  before 
a    subsidence    of    the    inflammatory    symptoms    can    be    reasonably 


CHRONIC    INFLAMMATION.  71 


expected.  Gouty  and  rheumatic  conditions  may  be  relieved  by  a  care- 
fully-selected diet  and  the  administration  of  the  salicylic  compounds; 
while  inflammations  depending  upon  blood-poisoning  will  demand 
other  special  agents  adapted  to  the  elimination  of  specific  micro- 
organisms and  their  products,  such  as  the  compounds  of  mercury  and 
iodin. 


CHAPTER  VII. 
ABSCESS. 

Definition. — Abscess  (Lat.  ahscedere,  to  depart). 

An  abscess  is  an  accumulation  of  pus  in  the  tissues  surrounded  by 
a  wall  of  lyinph  (formerly  termed  the  pyogenic  membrane,  from  the 
■erroneous  notion  that  it  secreted  pus).  An  abscess  may  be  termed  a 
liollow  ulcer. 

When  a  collection  of  pus  occurs  in  such  locations  as  the  pleura, 
pericardium.  Fallopian  tubes,  pelves  of  the  kidneys,  peritoneum,  etc.,' 
the  prefix  pyo,  added  to  the  anatomical  name  of  the  locality,  indicates 
the  presence  of  pus;  thus:  Pyo-thorax,  pyo-pericardium,  pyo-salpinx, 
pyo-nephrosis,  pyo-peritonitis,  pyo-ulitis. 

Causes. — Suppurative  inflammation  always  precedes  the  formation 
of  an  abscess.  Excessive  and  continued  irritation  causes  so  copious  an 
exudation  that  the  lymph-channels  are  blocked,  complete  blood-stasis 
occurs,  and  coagulation  follows.  The  leucocytes  lose  their  vitality, 
pressure  upon  the  connective-tissue  cells  involved  in  the  inflamed  area 
produces  a  like  result  in  them,  and  by  the  action  of  the  micro-organ- 
isms which  have  gained  an  entrance  through  the  circulation  or  by  other 
avenues,  the  tissues  and  exudates  are  converted  into  pus. 

When  the  bacteria  accumulate  in  a  mass,  as  they  frequently  do, 
at  some  particular  point  in  the  system,  the  concentrated  action  of  the 
bacteria,  or  of  the  chemical  product,  causes  coagulation  of  the  serum 
and  of  the  contiguous  tissue, — "coagulation  necrosis," — thus  forming 
a  nidus  or  central  point  for  the  development  of  suppuration,  and  the 
formation  of  an  abscess.  Around  this  central  point,  composed  of  dead 
tissue,  and  containing  a  nest  of  micro-organisms,  the  leucocytes 
accumulate  in  great  numbers,  completely  inclosing  it  by  forming  a 
kind  of  wall.  The  central  mass  of  dead  tissue,  and  the  immediately 
surrounding  intercellular  substance,  soon  begin  to  liquefy.  This  liber- 
ates the  leucocytes,  which  were  entangled  in  the  meshes  of  the  inter- 
cellular substance,  and  they  become  mixed  with  the  pus.  This  pro- 
cess continues,  and  the  fluid  contents  of  the  abscess  gradually  increase 
in  amount;  tension  of  the  tissues  results,  and  they  eventually  give  way 
at  the  location  offering  the  least  resistance.  This  is  termed  "pointing," 
and  through  this  opening  the  contents  are  discharged.  Active  cell 
proliferation  in  the  fixed  tissue-cells  is  going  on  at  the  same  time  in 
72 


ABSCESS.  73 

the  outer  portion  of  the  wall  of  leucocytes.  Lining  the  abscess  cavity 
is  a  tissue  known  as  "graniilation-tisstic,"  which  by  its  growth  repairs 
the  damage  caused  by  the  destruction  of  tissue.  This  tissue  is  com- 
posed chiefly  of  small,  round  cells,  with  scanty  intercellular  substance, 
but  very  rich  in  capillary  blood-vessels. 

Classification. — Abscesses  may  be  classed  as  superHcial  and  deep- 
seated,  difftise  (phlegmonous)  and  circninscribed,  acute  and  chronic. 

Supcj'ticial  or  subcutaneous  abscesses  have  a  tendency  to  spread 
laterally.  This  is  explained  by  the  fact  that  the  pus  moves  in  the  direc- 
tion of  the  least  resistance.  The  loose  subcutaneous  connective  tissue 
favors  this  route  of  extension,  and  offers  but  little  resistance  to  the 
pressure  caused  by  the  accumulated  pus. 

Deep-seated  or  sub-fascial  abscesses  burrow  along  the  sheaths  of 
muscles  and  blood-vessels  in  the  connective  tissue,  and  may  even  dis- 
sect the  periosteum  from  the  bone.  Such  cases  are  not  infrequently 
met  with  in  connection  with  abscesses  of  the  neck  resulting  from 
abscessed  teeth,  or  abscesses  resulting  from  the  irritation  of  unerupted 
lower  third  molars,  and  in  compound  fractures  of  the  lower  jaw  fol- 
lowed by  septic  inflammation.  Inflammation  of  the  lymphatic  glands 
situated  in  the  upper  triangle  of  the  neck,  or  in  the  submaxillar}^  tri- 
angle, frequently  results  in  the  formation  of  deep-seated  abscesses, 
which  burrow  downward  to  the  anterior  mediastinum.  This  is  caused 
by  their  inability  to  penetrate  the  deeper  layer  of  the  cervical  fascia,  the 
action  of  the  law  of  gravitation  which  carries  the  pus  downward,  and 
the  slight  resistance  offered  by  the  intermuscular  connective  tissue. 

The  retropharyngeal  abscess  is  an  example  of  a  still  deeper  variety. 
This  abscess  is  situated  in  the  space  between  the  oesophagus  and  the 
spine.  The  anatomical  relations  of  the  part  prevent  the  pointing  of 
the  abscess  at  its  primary  seat;  the  oesophagus  being  in  front,  the  spine 
behind,  and  the  sheaths  of  the  blood-vessels — which  are  quite  unyield- 
ing in  this  location — on  either  side,  while  the  space  between  is  com- 
posed of  loose  connective  tissue,  which  favors  its  downward  course 
into  the  posterior  mediastinum.  In  the  early  stages  the  symptoms  are 
often  not  well  marked.  Such  abscesses  occasionally  point  at  or  near 
the  jaw,  but  more  often  they  follow  the  downward  course  already  indi- 
cated. Retropharyngeal  abscesses  usually  originate  in  a  tubercular 
nodule  located  in  the  body  of  a  cervical  vertebra. 

Diffuse  (spreading, — phlegmonous)  abscess  is  a  term  applied  to 
that  form  of  abscess  which  spreads  in  various  directions.  Its  location 
may  be  in  the  subcutaneous  connective  tissue,  submucous  tissue,  inter- 
muscular connective  tissue,  or  subperiosteal  tissue.  This  form  of 
abscess  is  caused  by  the  infection  of  the  tissues  with  the  pus-producing 
streptococci,  and  the  favorite  routes  through  which  it  spreads  are  the 
connective  tissues  and  the  lymphatic  glands.     The  term  diffuse  purulent 


74  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

infiltration  is  sometimes  applied  to  this  form  of  abscess.  In  this  type 
of  the  afifection,  all  the  symptoms  of  acute  inflammation  are  present, 
and  the  extent  of  the  involved  tissue  is  often  considerable.  The  swell- 
ing is  usually  great,  and  the  surface  of  the  distended  integument  may 
develop  vesicles  filled  with  serum.  The  constitutional  symptoms  are 
also  well  marked,  the  disturbance  sometimes  being  profound.  Famil- 
iar examples  of  this  form  of  abscess  are  those  associated  with  infectious 
inflammations  of  compound  fractures,  and  other  injuries.  Phleg- 
monous erysipelas  is  a  more  severe  form  of  this  same  type  of  inflamma- 
tion. The  diffuse  suppurative  inflammation  following  the  infection  of 
dissecting  wounds,  "malignant  edema,"  is  the  gravest  form  of  the  affec- 
tion. In  this  type  of  inflammation  the  process  is  very  rapid  and 
intense,  the  tissues  are  quickly  overwhelmed  by  the  action  of  the 
poison,  resulting  in  extensive  death  of  the  tissues,  and  sometimes 
causing  a  fatal  termination  from  acute  septicemia  before  the  suppu- 
rative process  has  become  established. 

Circumscribed  abscess  is  a  term  used  to  designate  a  form  of  abscess 
possessing  defined  limits.  This  is  the  most  common  form  of  abscess. 
It  is  the  result  of  a  suppurative  inflammation,  having  limited  or  circum- 
scribed boundaries,  and  is  an  opposite  condition  to  diffuse  abscess  or 
purulent  infiltration.  A  furuncle  (boil)  or  an  alveolar  abscess  are 
common  examples  of  this  form  of  the  affection.  Circumscribed 
abscess  may  be  located  in  any  part  of  the  body,  in  any  vascular 
tissue.  It  is  also  occasionally  found  in  the  ivory  of  the  elephant's  tusk 
(a  non-vascular  tissue)  at  considerable  distances  from  the  pulp,  and 
completely  encapsuled.  Such  conditions  must  have  been  the  result  of 
injury  to  the  pulp  of  the  tusk,  as  suppuration  in  a  tissue  without  a  vas- 
cular system  is  an  impossibility.  Professor  Busch,  of  Berlin,  exhibited 
several  specimens  of  this  character  at  the  Ninth  International  Medical 
Congress,  held  at  Washington,  D.  C,  in  1887.  He  beheved  them  to  be 
the  result  of  injury  to  the  pulp,  causing  suppurative  inflammation. 
The  tusk  of  the  elephant  grows  continually  during  the  life  of  the  ani- 
mal; the  odontoblasts  must,  therefore,  be  in  a  state  of  constant  func- 
tional activity,  which  would  explain  the  fact  of  the  abscess  cavities 
being  removed  to  such  distances  from  the  pulp  by  growth  of  the  tissue 
from  its  base.  This  would  also  explain  the  encapsulation  of  the  pus 
by  the  formation  of  secondary  dentine.  In  all  of  these  specimens  the 
pus  was  dried  up,  leaving  the  cavity  empty. 

The  micro-organisms  most  commonly  found  in  acute  abscesses  are 
the  staph3dococci  and  the  streptococci.  The  pus  found  in  cold 
abscesses  often  contains  but  few  micro-organisms,  and  sometimes  it 
seems  to  be  entirely  free  from  them. 

The  staphylococcus  is  more  frequently  found  in  circumscribed 
abscesses,  while  the  streptococcus  is  more  prone  to  give  rise  to  diffuse 
purulent  infiltration. 


AIJSCESS.  75 

The  size  of  the  abscess  will  be  determined  by  the  character  of  the 
primary  cause  of  the  inflammation,  its  location,  the  age,  habit  of  life, 
and  diathesis  of  the  patient,  and  the  condition  of  the  tissues  involved. 

Tissues  which  have  been  debilitated  by  a  previous  inflammation, 
a  contusion  or  other  injury,  have  not  the  same  resistive  powers  as 
healthy  tissues;  consequently  abscesses  developing  in  these  locations 
reach  much  greater  dimensions.  In  individuals  whose  vital  powers 
have  been  impaired  by  old  age,  improper  or  insufficient  food,  the  drink 
habit,  mental  anxiety,  or  some  previous  acute  or  chronic  ailment,  acute 
suppurative  inflammation  has  a  greater  tendency  to  rapid  extension 
than  in  healthy  persons. 

Acute  Abscesses. — An  acute  abscess  or  hot  abscess  is  the  usual 
termination  of  an  acute  circumscribed,  suppurative  inflammation.  Its 
most  common  location  is  the  connective  tissue.  Its  direct  cause  is 
infection  from  micro-organisms, — the  staphylococcus  most  frequently. 
Its  contents  are  the  characteristic  yellowish,  cream-like  pus  and  shreds 
of  devitalized  connective  tissue.  It  runs  a  rapid  course,  reaching  its 
maximum  size  in  a  few  days  after  the  first  signs  of  inflammation  have 
appeared. 

The  opening  of  the  pulp-chamber  of  a  devitalized  tooth,  which 
before  had  been  impervious,  or  the  plugging  with  a  dressing  or  a  filling 
of  an  open  pulp-canal,  either  with  or  without  a  sinus  through  the  alve- 
olus, is  sometimes  immediately  followed  by  an  acute  phlegmonous 
inflammation,  when  strict  antiseptic  precautions  have  not  been  taken, 
or  the  caliber  of  the  canals  is  so  small  as  to  preclude  the  possibility  of 
rendering  them  aseptic.  In  such  cases  the  inflammation  rapidly 
extends  to  the  surrounding  connective  tissue,  producing  septic  cellu- 
litis, w^hich  follows  along  the  intermuscular  septa,  fascia,  etc.,  with 
great  swelling  and  tension,  and  accompanied  with  lymphangitis.  The 
constitutional  symptoms  are  marked  by  high  temperature,  rigors,  fol- 
lowed by  profuse  sweating,  and  other  symptoms  of  grave  disturbance. 
Occasionally  it  may  result  in  gangrene,  and  finally  death  of  the  patient. 
One  case  of  this  character,  associated  with  a  lower  third  molar  as  the 
starting  point  of  the  inflammation,  came  under  the  observation  of  the 
writer  at  Mercy  Hospital. 

Symptoms. — The  local  diagnostic  signs  or  symptoms  of  acute 
abscess  are,  throbbing  pain,  increasing  swelling,  surface  reddened, 
and  sometimes  glazed;  fluctuation  discovered  by  palpation,  percussion, 
and  pressure;  tendency  to  point.  Pointing  always  occurs  at  the  loca- 
tion of  least  resistance.  Constitutional  symptoms  are  rigors,  fever, 
loss  of  appetite,  general  malaise,  and  thirst.  Under  ordinary  circum- 
stances the  diagnosis  is  simple,  but  occasionally  it  becomes  more  diffi- 
cult on  account  of  the  modification  of  the  symptoms,  depending  upon 
the  primary  cause  of  the  suppurative  inflammation,  its  location,  and 
the  character  of  the  tissues  involved. 


76  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

Grave  blunders  have  sometimes  occurred  through  relying  too 
implicitly  upon  one,  or  even  all,  of  the  symptoms,  when  so  modified. 
Aneurisms  have  been  opened  under  the  belief  that  they  were  abscesses. 
An  angeioma  may  likewise  be  mistaken  for  an  abscess.  To  avoid  such 
accidents,  the  exploring  needle,  or  exploring  syringe,  should  always 
be  used  in  doubtful  cases.  Too  much  care  cannot  be  exercised,  as 
some  of  the  ablest  and  most  careful  surgeons  have  had  these  unfor- 
tunate experiences. 

Treatment. —  "Ubi  pus  ibi  evaciio."  This  rule  is  as  wise  to-day  in 
the  treatment  of  acute  abscesses  as  it  was  centuries  ago.  Many  sur- 
geons have  abandoned  expectant  treatment,  and  now  cut  down  upon 
the  abscess  as  soon  as  a  sufficient  quantity  of  pus  has  been  formed  to 
make  the  diagnosis  clear.  Much  suffering  may  be  saved  by  the  adoption 
of  this  method  of  treatment. 

In  opening  an  abscess,  the  surface  should  always  be  first  carefully 
cleansed,  and  other  antiseptic  precautions  observed,  while  the  incision 
should  be  made  at  the  most  dependent  part.  In  large  abscesses,  sev- 
eral small  incisions,  not  over  an  inch  in  length,  are  better  than  one 
large  one  which  lays  open  the  entire  cavity.  Evacuate  the  pus  and 
irrigate  the  cavity  with  some  bland  antiseptic  solution, — boric  acid  or 
Thiersch  solution, — until  the  fluid  runs  clear,  after  which  insert  one  or 
more  drainage-tubes,  as  the  case  may  require,  and  dress  with  antiseptic 
gauze,  oakum,  or  other  sterilized  material. 

Antiseptic  solutions. — The  trend  of  treatment  by  antiseptic  solu- 
tions to-day  is  toward  those  which  do  not  coagulate  the  proteid  ele- 
ments. Corrosive  sublimate  has  been  considered  as  the  most  valuable 
of  all  the  drugs  for  use  in  antiseptic  surgery,  and  this  idea  has  been 
most  thoroughly  instilled  into  the  minds  of  medical  and  dental  stu- 
dents. Koch,  through  whose  experiments  and  statements  the  mer- 
curic chlorid  solutions  received  such  a  boom,  exaggerated  its  antiseptic 
value,  or  overlooked  the  differences  which  must  always  be  reckoned 
upon  between  laboratory  experiment  and  clinical  experience. 

The  coagulating  property  of  the  mercuric  chlorid  is  undoubtedly 
a  great  hindrance  to  its  practical  usefulness,  as  it  reduces  its  powers  of 
penetration. 

Sir  Joseph  Lister  has  recently  announced  that  he  has  entirely 
abandoned  the  use  of  the  sublimate  solution  in  favor  of  carbolic  acid. 
He  says,  "A  5  per  cent,  solution  of  carbolic  acid  is  more  trustworthy 
as  a  germicide,  for  surgical  purposes,  than  corrosive  sublimate,  and  in 
other  respects  greatly  to  be  preferred. 

"A  great  advantage  of  phenol  seems  to  be  that  it  has  a  powerful 
affinity  for  the  epidermis,  penetrating  deeply  into  its  substance,  and 
mixing  with  fatty  materials  in  any  proportion." 

Some  of  our  best  surgeons  have  to-day  discarded  all  antiseptic 


ABSCESS.  "jy 

drugs,  relying  upon  soap  and  sterilized  water  for  cleansing  the  sur- 
faces, sterilized  water  alone  for  all  other  purposes,  and  simple  sterilized 
materials  for  dressings,  and  they  claim  as  good  results  as  when  they 
depended  upon  antiseptic  drugs. 

This  emphasizes  the  fact  that  it  is  better  to  prevent  the  ingress  of 
pathogenic  micro-organisms  than  to  attempt  to  destroy  them  after  they 
have  gained  entrance  to  the  tissues;  also  that  surgical  cleanliness  is 
more  valuable  than  drugs. 

In  wounds,  and  in  suppurative  conditions  of  the  oral  cavity,  anti- 
septic solutions  are  indispensable,  but  solutions  of  mercuric  chlorid  and 
carbolic  acid  have  no  advantages  over  the  boric  acid  or  the  Thiersch 
solutions,  while  they  have  the  disadvantage  of  being  irritating  to  the 
mucous  membrane  if  used  of  sufficient  strength  to  be  of  real  value  as 
germicides,  as  well  as  poisonous  if  by  accident  they  enter  the  stomach. 

Methods  of  Opening  Abscesses. — Abscesses  as  large  as  a  hen's 
^ZZ  will  not  generally  require  more  than  one  incision. 

In  deep-seated  abscesses,  it  is  best  to  incise  the  skin  and  fascia, 
and  then  with  a  pair  of  sharp-pointed  hemostatic  forceps  tunnel  the 
tissue  until  the  abscess  is  reached;  then  unlock  the  handles  of  the  for- 
ceps and  separate  the  blades  sufficiently,  so  that  on  withdrawing  the 
forceps  an  opening  will  be  made  large  enough  to  admit  a  drainage-tube 
of  the  proper  diameter.  This  method  is  especially  valuable  when  the 
abscess  is  located  in  the  neighborhood  of  important  vessels  and  nerves, 
as  it  thereby  greatly  reduces  the  dangers  of  wounding  them.  It  is  the 
safest  method  to  follow  in  opening  large,  deep-seated  abscesses  in  the 
neqk. 

In  the  treatment  of  alveolar  abscesses,  the  disease  may  be  cut  short 
by  trephining  the  external  alveolar  plate  at  the  point  of  suppuration. 
To  prevent  a  recurrence,  the  pulp-canals  must  be  rendered  aseptic, 
and  maintained  in  that  condition  by  proper  dressings,  temporary  or 
permanent  fillings. 

Dressings. — In  the  application  of  dressings  to  external  abscesses, 
care  should  be  taken  to  insure  equable  compression,  that  the  surfaces  of 
the  abscess  cavity  may  be  kept  in  apposition.  Where  drainage-tubes 
are  used,  these  should  be  shortened  from  time  to  time,  and  entirely 
removed  as  soon  as  suppuration  has  ceased. 

Healing  of  Abscesses. — Abscess  cavities,  when  aseptic,  heal  by 
granulation.  Absolute  rest  of  the  part  is  a  valuable  adjunct  to  the 
treatment.     Patients  with  large  abscesses  should  be  kept  in  bed. 

The  principal  causes  of  retarded  healing  are  imperfect  drainage, 
non-apposition  of  granulation  surfaces,  hemorrhage,  rupture  of  the 
limiting  walls,  permitting  infiltration  of  pus  into  the  surrounding  con- 
nective tissues,  indolent  granulations,  or  constitutional  dyscrasia.  In 
the  latter  conditions,  general  tonic  treatment  is  indicated. 


yS  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

Chronic  Abscess. — Chronic  abscess  differs  from  the  acute  form  in 
that  its  course  is  slow,  the  signs  or  symptoms  are  greatly  modified,  or 
wanting  altogether.  It  is  usually  painless,  not  tender  to  the  touch, 
and  causes  little  or  no  febrile  disturbances.  The  tendency  to  point  is 
less  marked,  and  pus  accumulates  often  to  an  extraordinary  amount 
before  the  skin  shows  any  sign  of  yielding.  Generally  the  pus-cor- 
puscles are  considerably  disintegrated,  the  abscess  walls  are  greatly 
thickened,  and  show  signs  of  organization  into  connective  tissue,  and 
with  very  little  tendency  toward  healthy  granulation. 

The  condition  is  one  of  passive  congestion,  with  slight  develop- 
ment of  inflammatory  heat;  hence  the  terms,  congestive  abscess  and 
cold  abscess. 

Causes. — Chronic  abscess  may  generally  be  traced  to  some  specific 
chronic  inflammation,  most  often  of  a  tubercular  nature.  The  forms 
most  frequently  coming  under  the  observation  of  the  oral  surgeon  are 
alveolar  abscesses,  caused  by  specific  infection  from  devitalized  teeth, 
abscesses  of  the  face  and  neck  from  chronic  inflammation  of  unerupted 
third  molars,  or  portions  of  necrosed  bone,  tubercular  or  syphilitic 
inflammation  of  the  jaws,  tubercular  inflammation  of  the  cervical 
glands,  and  retropharyngeal  abscess.  Abscesses  in  connection  with 
unerupted  third  molars  and  the  cervical  glands  often  burrow  down- 
ward, following  the  septa  between  the  muscles,  and  point  as  low  down, 
sometimes,  as  the  clavicle  and  mammae. 

When  large  chronic  abscesses  rupture  spontaneously,  or  are 
opened  with  the  bistoury,  profuse  suppuration  and  hectic  fever  quickly 
develop,  frequently  preceded  by  rigors,  and  followed  by  profuse 
sweating.  Occasionally,  under  such  conditions,  emaciation  is  rapid 
and  continuous,  and  the  patient  dies  from  septic  infection. 

Symptoms. — The  diagnosis  of  chronic  abscess  depends  more  upon 
the  careful  consideration  of  the  symptoms  of  the  local  lesion  from 
which  it  started  than  upon  the  location,  size,  and  special  features  of  the 
swelling.  (Senn.)  Tubercular  affections  are  usually  accompanied  by 
such  well-marked  symptoms  at  the  stage  when  abscesses  form,  that 
there  is  very  little  diflliculty  in  locating  the  primary  lesion.  The  same 
is  true  of  chronic  abscesses  originating  from  unerupted  third  molars. 

An  exploratory  puncture,  and  a  microscopic  examination  of  the 
contents  of  a  chronic  abscess,  will  many  times  be  necessary  to  a  posi- 
tive diagnosis  as  to  its  character. 

In  tuberculosis,  the  product  of  tissue  proliferation  coagulates,  dies, 
and  disintegrates  into  a  granular  mass,  which  when  mixed  with  serum 
in  sufficient  quantity  forms  an  emulsion  that  to  the  unaided  eye  closely 
resembles  pus,  but  which  the  microscope  proves  to  contain  none  of  the 
histologic  elements  found  in  pus. 

Secondary    infection    of    tubercular,    actinomycotic,    or    syphilitic 


ABSCESS. 


79 


lesions  may  take  place  from  the  localization  of  the  pus-microbe,  and 
true  chronic  abscess  result,  or  occasionally  be  followed  by  an  acute 
phlegmonous  inflammation.  Generally,  however,  no  acute  symp- 
toms develop. 

Treatment. — Surgical  interference  in  the  treatment  of  chronic 
abscess  is  never  so  urgent  as  in  the  acute  form,  on  account  of  its  slower 
development  and  slight  constitutional  disturbance. 

The  abscesses  appear  months,  and  sometimes  years,  after  the  first 
development  of  the  primary  cause. 

It  has  already  been  stated  that  acute  abscess  should  never  be 
opened  without  antiseptic  precautions.  This  principle  needs  to  be 
doubly  emphasized  in  the  treatment  of  chronic  abscess,  especially  that 
form  known  as  cold  abscess. 

The  antiseptic  precautions  in  the  latter  form  should  be  of  the  most 
rigid  and  elaborate  character,  in  order  to  guard  against  the  dangers 
from  septic  infection,  and  a  possible  fatal  result. 

To  avoid  these  dangers,  the  German  surgeons  advocate  evacuation 
by  aspiration,  and  iodoform  injections,  in  preference  to  incision  and 
drainage.  Aspiration  in  tubercular  abscess  is  generally  unsatisfactory, 
for  the  reason  that  the  needle  or  trocar  soon  becomes  clogged  by  the 
shreds  of  dead  tissue,  and  renders  complete  evacuation  impossible. 

In  those  cases  where  the  seat  of  the  primary  lesion  can  be  reached 
by  an  incision  of  the  abscess,  this  is  the  proper  method,  as  it  gives 
opportunity  to  remove  the  infected  tissue  or  the  cause  of  infection. 
The  abscess  cavity  should  then  be  thoroughly  scraped  out  (curetted), 
and  all  infected  tissue  removed,  cleansed  with  antiseptic  solutions, 
dried,  covered  with  iodoform  or  boric  acid,  and  treated  as  a  recent 
wound,  by  suturing,  drainage,  and  antiseptic  dressing. 

In  those  cases  caused  by  devitalized  teeth,  unerupted  teeth,  or 
necrosed  bone,  rational  treatment  would  demand  the  immediate 
removal  of  the  cause  of  irritation  as  soon  as  the  diagnosis  could  be 
made  clear.  Constitutional  treatment  comprehends  a  generous  diet, 
stimulants,  and  tonics, — iron,  cod-liver  oil,  etc. 


CHAPTER    VIII. 
ULCERATION. 

Definition. — Ulceration.     (Lat.  ulcus,  a  sore.) 

An  ulcer  is  an  open  sore;  a  destructive  loss  or  solution  of  contin- 
uity upon  any  of  the  free  surfaces  of  the  body,  which  will  not  permit 
of  repair  by  primary  union;  a  molecular  death  of  tissue. 

It  owes  its  existence  to  an .  excess  in  action  of  the  retrograde 
changes  over  those  of  repair. 

The  difiference  between  an  open  granulating  wound  and  an  ulcer 
is  that  the  wound  shows  a  tendency  to  heal,  while  the  ulcer  shows  no 
such  tendency,  but  on  the  contrary  is  often  inclined  to  spread.  The 
explanation  is  that  in  the  granulating  wound  the  primary  cause  has 
ceased  to  exist,  while  in  the  ulcer  it  is  still  persistent,  or  infection  has 
been  introduced.  An  open  granulating  wound  may  become  an  ulcer 
at  any  time  if  the  granulation-tissue  takes  on  a  retrogressive  change. 
This  change  may  be  induced  by  infection  with  the  pus-microbe,  from 
mechanical  or  chemical  irritation,  from  dressings,  the  presence  of  a 
foreign  substance,  or  the  chemical  action  of  drugs  applied  to  the 
wound. 

Ulceration  and  gangrene  are  closely  allied  to  each  other,  the  dif- 
ference being  that  ulceration  is  the  death  of  cells,  the  fixed  tissue-cells 
and  the  embryonic  or  new-formed  cells  ("cell  necrosis"),  while  gan- 
grene is  death  en  masse  of  tissue  (formed  tissue). 

All  wounds,  of  whatever  nature,  which  do  not  heal  by  primary 
union  or  "first  intention,"  heal  by  the  process  of  granulation.  (Fig. 
34.)  A  granulation  is  composed  of  a  capillary  loop  about  which  are 
clustered  a  number  of  living  leucocytes,  held  together  by  a  delicate 
intercellular  material.  Healthy  granulations  are  cherry  red  in  color, 
non-sensitive,  elastic,  and  discharge  a  laudable  pus. 

An  ulcer  is  quite  indefinite  as  to  its  size,  and  variable  as  to  its 
shape.  It  is  usually  round,  but  may  be  reniform,  irregular,  or  serpigi- 
nous. It  may  be  deep  or  shallow,  with  abrupt  or  with  sloping  sides,, 
and  a  smooth  or  an  irregular  base.  Its  edges  may  be  sharp  or  round, 
everted  or  undermined.  The  surface  is  covered  with  coarse  granula- 
tions, dark  red  in  color,  which  bleed  readily.  The  surface  may  be 
clean  or  sloughy,  and  covered  with  pus  or  serum.  On  healing,  it 
always  leaves  a  scar, 
80 


ULCERATION. 


8i 


Hbi^  a  vertical  section  of  an  nicer  examined  microscopically  reveals 
the  following  conditions:  First,  a  layer  of  pns  npon  the  surface;  pro- 
jecting" into  the  pus  fine  capillary  loops,  surrounded  by  living  leuco- 
cytes, constituting  granulations.  Beneath  this  is  a  zone  of  thickened 
inflammatory  tissue,  consisting  mainly  of  fine  fibrous  tissue,  and 
underneath  this  again  a  zone  of  hyperemia,  where  the  capillaries  are 
very  numerous,  and  the  leucocytes  are  in  excess.  Beyond  this  are 
healthy  tissues. 

Fig.  34. 


Granulation-Tissue — Blood-vessels  and  Matrix.     X  75. 


The  ulcerative  process  is  so  intimately  associated  with  inflamma^ 
tion,  suppuration,  gangrene,  phagedena,  granulation,  and  cicatriza- 
tion, that  it  is  impossible  to  detach  it  from  any  one  of  these  and  call 
it  a  separate  and  definite  process. 

Causes. — The  causes  of  ulceration  may  be  divided  into  constitu- 
tional and  local,  predisposing  and  exciting. 

The  predisposing  causes  are  those  which  operate  through  the 
general  system,  and  comprehend  changes  in  nutrition,  in  the  quantity 
and  quality  of  the  blood,  peculiar  dyscrasise  and  diatheses,  and  the 
freedom  and  rapidity  of  the  circulation.  Familiar  examples  are  seen 
in  persons  who  are  badly  nourished  or  debilitated  by  disease,  such  as 
tubercular  affections,  intestinal  disorders  accompanied  by  exhausting 
discharges,  typhoid  fever,  diabetes,  scurvy,  syphilis,  mercurial  poison- 
ing, and  dropsy, 

7 


82  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

The  exciting  causes  are  irritations  of  a  physical,  chemical,  or  septic 
nature. 

Age. — The  influence  of  age  is  often  stated  to  be  an  important 
factor  in  the  etiology  of  ulcers.  Old  age  is  without  doubt  a  period 
marked  by  many  retrogressive  tissue-changes,  and  by  diminished 
physical  power  and  vital  resistance,  which  predispose  to  and  favor  the 
ulcerative  process,  and  yet  statistics  show  only  a  very  slight  increase 
in  the  percentage  of  this  affection  among  the  aged. 

■^ex. — Sex  seems  to  be  a  potent  factor  in  the  determination  of 
ulcers.  Statistics  show  that  ulcers  are  three  times  as  prevalent  among 
men  as  among  women.  This  may  be  explained,  however,  by  the  fact 
that  men  are  subject  to  much  greater  exposure  to  injuries,  and  are 
more  liable  to  contract  syphilis  or  the  habit  of  intemperance. 

Occupation. — Occupation  owes  its  influence  to  the  degree  of 
exposure  to  traumatism.  The  greatest  number  of  individuals  suffer- 
ing from  ulcers  come  from  the  laboring  classes.  Among  the  most 
prominent  predisposing  causes  of  ulcers  are  neglect  and  filth.  It 
therefore  happens  that  a  greater  number  of  cases  of  ulceration  are 
found  among  that  class  of  individuals  whose  habits  of  personal  cleanli- 
ness are  not  good,  whose  means  or  lack  of  means  prevents  the  proper 
care  of  the  lesion  in  its  earlier  stages  when  it  might  be  easily  cured. 

Traumatism. — Traumatisms  are  the  most  frequent  cause  of  ulcers 
of  the  skin  and  mucous  membrane,  at  least  of  the  acute  variety.  The 
degree  of  injury  necessary  to  produce  an  ulcer  will  depend  upon  the 
individual  peculiarities  of  the  constitution.  The  young  and  the  robust 
adult  will  resist  an  injury  which  in  the  aged  might  result  in  extensive 
death  of  tissue.  In  the  feeble  and  those  afflicted  with  some  constitu- 
tional dyscrasia  like  tuberculosis,  syphilis,  gout,  diabetes,  etc.,  slight 
injury  often  causes  death  of  tissue,  with  sloughing  and  the  formation 
of  troublesome  ulcers. 

Classification. — Ulcers  are  usually  classed  according  to  their  mode 
of  origin,  and  are  divided  into  two  groups,  the  non-infectious  and  the 
infectiotis. 

Among  the  non-infectious  ulcers  may  be  classed  all  those  which 
are  caused  by  friction,  pressure,  and  other  mechanical  injuries,  and 
those  which  arise  from  chemical  irritation  or  from  trophic  changes 
due  to  enervation,  general  faulty  nutrition,  and  impeded  local  circula- 
tion. The  great  majority  of  ulcers  are  the  result  of  the  action  of  vari- 
ous forms  of  infectious  micro-organisms,  such  as  the  pyogenic 
bacteria,  those  of  tuberculosis,  syphilis,  leprosy,  glanders,  and  perhaps 
cancer.  Ulcers  which  are  not  caused  primarily  by  the  action  of  path- 
ogenic bacteria  usually  become  infected  as  soon  as  an  open  wound  is 
formed,  by  the  bacteria  invading  the  exposed  surfaces,  and  establish- 
ing the  inflammatory  process. 


ULCERATION. 


83 


Ulcers  are  also  classified  according-  to  certain  changes,  compli- 
cations or  modifications  which  may  occur  in  them.  These  changes, 
etc.,  are  indicated  in  the  terms  applied  in  the  classification,  such  as 
inftaiiicd,  crcthislic  (irritable),  fungous,  Jiciiwrrhagic,  torpid,  callous,  cor- 
roding, perforating,  phagedenic,  and  malignant  ulcers. 

An  inflamed  ulcer  is  one  having  its  base  and  surrounding  parts  in 
a  state  of  more  or  less  acute  inflammation;  the  surface  is  very  red;  it 
bleeds  easily,  and  the  formation  of  pus  is  plentiful.  The  edges  of  the 
ulcer  are  swollen  and  raised,  the  surrounding  skin  is  exceedingly  ten- 
der, dense  and  shining.  Ulcers  of  this  character  are  often  very  painful. 
The  causes  which  produce  these  conditions  are  neglect,  contact  with 
acrid  secretions,  or  the  application  of  substances  of  an  irritating  char- 
acter. 

The  erethistic  or  irritable  ulcer  possesses  extreme  sensitiveness 
which  is  exceedingly  difficult  to  relieve.  It  is  most  often  located  in 
parts  which  are  highly  sensitive,  like  the  anus.  These  ulcers  have 
the  appearance  of  granulating  surfaces  in  which  the  active  process 
of  repair  has  been  arrested.  The  edges  are  abrupt,  and  show  no 
evidence  of  a  tendency  to  cicatrize;  they  are  exceedingly  tender,  the 
slightest  touch  causing  intense  pain.  The  cause  of  the  exceeding 
sensitiveness  has  been  thought  to  be  the  thinness  of  the  granulation- 
tissue.  It  is  more  often  associated  with  nutritional  changes  due  to 
anemia  resulting  from  the  loss  of  blood  or  from  severe  disease.  Upon 
a  re-establishment  of  the  normal  conditions  of  nutrition,  the  exalted 
sensibility  passes  away. 

The  fungous  ulcer  is  the  result  of  an  exuberant  growth  of  granu- 
lation-tissue. It  is  caused  by  an  over-supply  of  blood  to  the  part, 
which  results  in  the  rapid  growth  of  capillary  loops  from  the  pre- 
existing blood-vessels,  while  the  epithelial  cells  present  a  sluggish 
kinetic  function,  which  retards  the  process  of  repair.  Fungous  gran- 
ulations in  a  wound,  or  an  ulcerating  surface,  are  popularly  known  as 
"proud  flesh."  Such  a  condition  is  an  obstacle  to  the  process  of 
repair.  Fungous  granulations  are  frequently  seen  protruding  from 
the  external  opening  of  fistulous  tracts,  especially  those  leading  to 
tubercular  abscesses,  necrosed  bone,  or  other  foreign  body.  Occa- 
sionally the  granulations  will  be  so  large  as  to  protrude  beyond  the 
surrounding  surface  of  the  skin,  sometimes  presenting  a  mushroom 
appearance,  with  a  narrow  pedicle.  This  condition  is  due  to  the 
growth  of  the  epidermis  into  the  granulation,  and  the  presence  of  a 
large  arteriole  at  the  base  of  the  granulation-tissue.  If  the  granula- 
tions are  cut  ofif,  they  are  reproduced  before  the  sluggish  epithelium 
incloses  the  wound.  Conditions  of  this  character  are  frequently 
associated  with  chronic  alveolar  abscesses  associated  with  pulpless 
teeth. 


84  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

The  hemorrhagic  ulcer  is  one  which  bleeds  upon  the  least  provoca- 
tion. It  is  most  frequently  seen  in  scurvy.  The  ulcerating  surface 
has  a  characteristic  livid  blue  color,  and  the  granulations  possess  an 
active  tendency  toward  disintegration.  Vicarious  hemorrhage  has 
been  observed  in  cases  in  which  there  has  been  an  arrest  of  the  bleed- 
ing from  hemorrhoids,  and  following  a  suppression  of  the  menses. 

Torpid  ulcers  are  those  which  show  no  active  tendencies  in  any 
direction.  They  are  seen  most  often  in  individuals  suffering  from  the 
debilitating  effects  of  acute  or  chronic  disease,  resulting  in  defective 
nutrition  and  impaired  or  diminished  blood-supply  to  the  affected  part; 
The  characteristic  color  of  the  granulation  is  pale  red,  and  the  pus 
which  is  formed  is  thin  and  watery. 

The  callous  ulcer  presents  a  dirty,  granulating  surface,  with  thin, 
muco-purulent  pus,  and  edges  raised  considerably  above  the  surface. 
The  skin  is  indurated  and  fixed  for  some  distance  around  the  ulcer. 
This  form  of  ulcer  exists  without  material  change  in  size  for  a  long 
time,  and  it  is  most  often  seen  in  connection  with  old  varicose  ulcers 
of  the  legs. 

Corroding  ulcer  is  one  which  causes  a  progressive  destruction  of 
the  soft  tissues,  usually  starting  in  the  form  of  a  cutaneous  affection 
which  assumes  the  form  of  a  boil — Delhi  boil — and  afterward  ulcer- 
ates, causing  considerable  loss  of  tissue.  Ulcers  associated  with  lupus 
may  also  be  classed  with  this  form,  as  it  shows  a  slow  but  constant 
tendency  to  spread  to  adjacent  cutaneous  tissue. 

Perforating  ulcer  (round  ulcer)  is  an  ulcerative  condition  of  the 
stomach,  usually  dependent  upon  local  obstruction  of  the  blood-vessels 
of  that  organ.  Its  most  common  location  is  the  posterior  wall  of  the 
pyloric  portion  of  the  stomach.  The  perforation  through  the  serous 
coat  of  the  stomach  wall  has  the  appearance  of  having  been  punched 
out  or  cut  out,  and  is  usually  round. 

Phagedenic  ulcer  is  one  which  spreads  rapidly,  causing  consider- 
able loss  of  tissue,  and  accompanied  by  great  local  irritation.  It 
usually  occurs  in  persons  who  are  broken  down  by  disease,  lack  of 
proper  nourishment,  or  debauchery,  and  is  seen  most  often  in  epi- 
demics of  hospital  gangrene,  in  ulcers  which  have  been  treated  by 
irritating  or  escharotic  substances,  and  in  mercurial  ptyalism.  The 
primary  syphilitic  lesion  sometimes  takes  on  a  phagedenic  form,  when 
it  becomes  very  obstinate  to  the  action  of  remedial  agents. 

Malignant  ulcers  are  those  which  run  a  rapid  course,  spread  in  all 
directions,  perforating  the  soft  parts,  and  causing  extensive  gangrene 
and  sloughing,  with  necrosis  of  bone.  The  constitutional  symptoms 
which  accompany  this  type  of  ulcer  are  often  profound,  and  not  infre- 
quently terminate  fatally.  The  class  of  individuals  in  whom  this  form 
of  ulcer  is  most  commonly  found  are  children  who  have  suffered  from 


ULCERATION.  85 

long  and  exhausting  illness,  or  whose  surroundings  are  unhealthy, 
and  the  food  scanty  and  unwholesome.  The  parts  most  frequently 
attacked  are  the  lips,  cheeks,  and  gums.  Noma  or  gangrsena  oris  is 
an  example  of  this  type  of  ulcer.  It  is  also  associated  with  epithelioma 
and  with  carcinoma  in  other  portions  of  the  body. 

The  forms  of  ulcers  most  interesting  to  the  oral  surgeon,  and 
which  most  frequently  come  under  his  observation,  are  simple  fol- 
licular ulceration  of  the  mucous  membrane,  aphthae,  syphilitic  mucous 
patches,  deep  syphilitic  ulcerations,  sloughing  phagedena  following 
mercurial  ptyalism  and  scurvy,  cancrum  oris,  gangrsena  oris,  ulcera- 
tion associated  with  cancerous  growths,  and  lupus. 

Healing. — The  process  of  healing  in  ulceration  is  by  granulation 
and  cicatrization.  During  the  process  of  healing  the  dead  parts  of 
the  ulcer  come  away  as  a  thin,  ichorous  discharge,  the  exudates 
beneath  and  around  become  vascularized,  and  capillary  loops  shoot 
up  toward  the  surface.  Large  numbers  of  leucocytes  cluster  around 
these,  forming  a  surface  of  healthy  granulation,  which  then  discharge 
a  thin,  creamy  pus,  the  laudable  pus  of  the  old  writers. 

Cicatrization  is  the  process  of  covering  or  skinning  over  the  new 
tissue  formed  by  granulation.  During  this  process  the  surrounding 
surface  of  the  skin  sinks  to  the  level  of  the  granulation,  the  epithelial 
cells  at  the  edge  of  the  ulcer  undergo  segmentation  or  karyokinesis, 
and  grow  toward  the  center  of  the  ulcer.  This  is  denoted  by  a  blue 
film,  and  while  this  is  extending  the  new  tissue  of  the  ulcer  is  contract- 
ing from  the  conversion  of  the  leucocytes  into  fibrous  tissue.  Con- 
traction does  not  stop  with  the  healing  of  the  ulcer,  but  continues  for 
a  considerable  period  afterward,  and  sometimes  causes  very  great 
deformity.  A  cicatrix  has  neither  nerves,  glands,  lymphatics,  nor  hair, 
and  when  injured  it  does  not  heal  readily,  and  is  prone  to  ulceration. 

Prognosis. — The  prognosis  of  an  ulcer  depends  upon  several  fac- 
tors, viz:  The  nature  and  primary  cause,  the  situation,  the  age  and 
constitution  of  the  patient,  and  the  complications.  The  complication 
most  likely  to  occur  is  septic  infection.  Like  open  wounds,  ulcers  are 
constantly  exposed  to  this  danger,  and  when  the  fact  of  neglect  and 
filthiness,  as  often  seen  in  the  out-patients  who  visit  the  infirmaries  in 
our  large  cities,  is  taken  into  consideration,  it  seems  wonderful  that 
more  cases  are  not  complicated  with  some  form  of  septic  poisoning. 
The  erysipelatous  streptococcus  is  a  frequent  cause  of  septic  infection 
of  ulcers,  and  is  most  commonly  seen  among  ignorant  individuals  who 
are  filthy  in  their  habits.  Cases  of  this  character  may  have  progressed 
to  such  an  extent  before  they  are  seen  by  the  surgeon  as  to  render 
treatment  of  no  avail,  and  a  fatal  termination  is  quickly  reached. 
Adenitis  resulting  in  extensive  suppuration  of  the  glands  from  sepsis 
is  another  form  of  complication  which  may  terminate  in  death  from 


86  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

hectic  fever,  exhaustion,  and  amyloid  degeneration  of  the  liver  and 
kidneys,     (Minot.) 

The  most  important  and  dangerous  complication  is  perforation 
of  some  important  internal  viscus,  like  the  stomach,  intestines,  or 
bladder,  which  establishes  septic  inflammation  of  the  peritoneal  cavity; 
or  malignant  and  syphilitic  ulcers,  which  perforate  the  cheek  or  palate 
and  nasal  septum.  Peritonitis  is  the  inevitable  consequence  of  perfor- 
ation of  an  internal  viscus  in  those  cases  in  which  the  ulcerative  process 
has  been  rapid.  When  the  ulceration  progresses  more  slowly,  nature 
attempts  to  prevent  perforation  by  establishing  a  plastic  inflammation 
and  thickening  of  the  outer  wall  of  the  viscus  at  the  base  of  the  ulcer, 
and  also  of  the  peritoneum  lining  the  abdominal  walls,  or  covering 
some  adjacent  organ,  resulting  in  adhesion  of  the  surface  in  contact 
with  it,  and  perforation  of  the  wall  of  the  adherent  organ  without  enter- 
ing the  peritoneal  cavity. 

Hemorrhage  is  sometimes  a  serious  complication,  calling  for  liga- 
tion of  the  arterial  trunk  supplying  the  locality  of  the  ulcer.  This  is 
most  likely  to  occur  in  malignant  ulcers,  ulceration  associated  with 
malignant  tumors,  and  in  ulceration  of  varicose  veins  of  the  leg.  The 
severity  of  the  hemorrhage  may  be  such  as  to  endanger  life.  Hem- 
orrhages occurring  in  ulcers  upon  the  surface  of  internal  organs  are 
often  fatal  from  their  inaccessibility  to  surgical  treatment. 

Ordinary  ulcers  of  the  skin  and  mucous  membrane  of  traumatic 
or  idiopathic  origin  are  never  dangerous  to  life  except  through  septic 
infection.  The  curability  of  an  ulcer  will  depend  largely  upon  the 
nutrition  of  the  part,  the  character  of  the  treatment,  and  the  amount 
of  care  exercised  in  carrying  out  its  details. 

Treatment. — The  treatment  of  ulcers  in  general  must  be  directed 
both  to  the  local  and  constitutional  conditions.  The  local  treatment 
consists  primarily  in  improving  the  circulation  of  the  part.  Passive 
hyperemia  usually  exists,  and  it  is  necessary  to  relieve  this  condition 
in  order  that  the  parts  may  regain  their  normal  function,  and  thus  be 
enabled  to  carry  out  the  process  of  repair.     (Warren.)  . 

Ulcers  as  they  come  under  the  observation  of  the  surgeon  are 
usually  more  or  less  in  a  state  of  inflammation  from  the  presence  of 
micro-organisms  or  other  irritating  substances  which  prevent  the 
estabHshment  of  the  healing  process.  Rational  treatment  would 
therefore  be  directed  first  to  the  removal  of  the  cause  of  irritation,  and 
the  adoption  of  means  which  would  relieve  the  inflammatory  symp- 
toms. These  ends  may  be  accomplished  by  rest  of  the  part,  cleanli- 
ness, antiseptic  compresses  saturated  with  hot  antiseptic  solutions, 
antiseptic  dressings,  and,  if  the  disease  is  located  in  an  extremity,  ele- 
vation of  the  limb  to  a  higher  level  than  the  rest  of  the  body,  as  this 
favors  relief  of  the  hyperemic  condition  of  the  part.     Rest  in  bed  is 


ULCERATION.  87 

always  advisable  in  an}^  case  of  serious  ulceration.  Care  must  be  ex- 
ercised, when  using-  moist  compresses  and  dressings,  that  the  tissues 
are  not  injured  by  too  long  an  application  at  one  time;  twenty-four  co 
thirty-six  hours  is  as  long  as  the  tissues  should  be  subjected  to  this 
kind  of  treatment  without  intermission.  In  addition  to  the  above 
treatment,  accumulations  of  pus  in  the  cellular  tissue  or  adjacent 
glands  should  be  evacuated  by  free  incisions  and  the  establishment  of 
ample  drainage.  If  erysipelas  is  present  it  is  best  to  treat  this  condition 
by  the  use  of  wet  compresses  wrung  out  of  hot  bichlorid  solution  of 
the  strength  of  one  to  one  thousand,  or  one  to  two  thousand,  in  water. 

In  a  majority  of  cases  an  ordinary  ulcer  will  begin  to  heal  as  soon 
as  the  inflammatory  symptoms  have  subsided.  Indolent  ulcers  may 
be  stimulated  by  the  application  of  balsam  of  Peru,  nitrate  of  silver, 
alum,  permanganate  of  potash,  sulfate  of  copper  or  zinc,  chromic 
acid,  iodin,  boric  acid,  and  ichthyol.  Numerous  drugs  have  been 
recommended  for  their  stimulating  qualities,  but  the  above  mentioned 
are  sufficient  to  indicate  this  class  of  remedies. 

Balsam  of  Peru  is  an  excellent  remedy  and  one  of  the  oldest  for 
stimulating  the  growth  of  granulations  in  that  class  of  external  chronic 
ulcers  and  granulating  wounds  in  poorly  nourished  individuals  in 
which  the  process  of  healing  has  been  established,  but  progresses  very 
slowly. 

Nitrate  of  silver  is  used  in  solution  of  5  to  10  grains  to  the  fluid- 
ounce  of  water,  as  a  stimulating  application  to  ulcers  of  the  mucous 
membrane.  It  is  also  used  in  stick  form,  freely  applied,  for  the  pur- 
pose of  destroying  unhealthy  granulations.  To  stimulate  the  base  of 
the  ulcer  it  may  be  lightly  applied  so  as  to  leave  only  the  slightest 
evidence  of  an  eschar. 

Alum  applied  in  powder  or  solution  acts  through  its  irritating  and 
astringent  properties. 

Permanganate  of  potash,  in  solution  of  from  5  to  10  grains  to  the 
fluidounce,  is  an  excellent  stimulant  to  chronic  ulcers,  but  sometimes 
these  strengths  will  prove  painful,  and  weaker  solutions  must  be  used. 
Solutions  of  copper  and  zinc  sulfate  of  about  the  same  strength  often 
prove  themselves  to  be  valuable  remedies  in  the  same  class  of  cases. 

Chromic  acid  is  of  value  in  secondary  syphilitic  ulcers  of  the 
mucous  membrane,  especially  of  the  mouth,  and  in  noma.  A  solution 
of  10  grains  to  the  fluidounce  of  water  will  sometimes  cause  the  former 
to  heal  without  the  aid  of  constitutional  treatment.  In  noma  it  is 
claimed  to  be  beneficial  by  destroying  the  diseased  tissue,  and  thus 
giving  opportunity  for  the  formation  of  healthy  granulations,  but  in 
the  writer's  experience  nothing  has  proved  of  permanent  benefit  in 
cases  of  true  noma. 

Iodin  and  iodoform  are  the  best  remedies  in  tubercular  ulcers. 


88  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

Boric  acid  has  a  wide  range  of  usefulness  in  the  treatment  of  all 
forms  of  ulcers,  being  antiseptic  as  well  as  stimulating. 

Ichthyol  was  introduced  to  the  profession  by  Unna  as  a  stimu- 
lant to  the  growth  of  epithelium,  but  it  is  also  a  valuable  aid  to  the 
growth  of  granulations.  It  may  be  employed  in  a  lo  per  cent,  solu- 
tion, but  it  is  most  commonly  applied  in  the  form  of  an  ointment  of  a 
25  per  cent,  strength. 

Operative  Treatment. — Skin-grafting  and  plastic  flap  operations 
are  sometimes  employed  to  close  extensive  open  wounds  and  ulcers, 
caused  by  loss  of  tissue  from  surgical  operations  and  other  trauma- 
tisms, particularly  those  following  burns  and  scalds.  The  Thiersch 
method  of  skin-grafting  is  generally  considered  the  best,  and  consists 
of  cutting  thin  shavings  of  healthy  skin  from  an  arm  or  a  leg,  and 
applying  them  to  the  surface  of  the  ulcer  or  granulating  wound,  which 
has  been  previously  prepared  to  receive  them  by  removing  the  granu- 
lations and  arresting  the  hemorrhage.  The  grafts  are  then  gently 
pressed  down  and  held  in  position  by  cotton  dressing  saturated  with  a 
salt  solution,  and  protected  by  rubber  tissue  and  a  bandage.  The 
dressing  is  changed  in  twenty-four  hours,  and  renewed  as  often  as  the 
case  requires.  Antiseptic  solutions  are  not  used,  but  the  dressings 
are  kept  moist  with  a  sterilized  salt  solution.  Large  surfaces  are 
frequently  covered  at  a  single  sitting  by  this  method. 

Plastic  flap  operations  are  sometimes  utilized  to  cover  granula- 
tions of  moderate  size,  and  to  fill  gaps  caused  by  the  loss  of  tissue  in 
the  removal  of  tumors.  These  flaps  are  taken  from  adjacent  tissue, 
but  always  in  such  a  way  as  to  leave  a  broad  pedicle  through  which 
the  flap  is  nourished  until  such  time  as  union  takes  place  between  the 
flap  and  the  granulating  surface.  The  flap  is  stitched  to  the  edges  of 
the  ulcer  after  they  have  been  freshened,  and  it  is  then  treated  as  a 
recent  wound. 

Sponge-grafting  is  another  method  of  hastening  the  process  of 
healing  of  ulcers  and  granulating  wounds.  The  sponge  is  prepared 
by  first  decalcifying  it  by  soaking  in  nitro-hydrochloric  acid,  and  then 
washing  it  in  an  alkaline  solution  to  remove  the  acid  and  preserving  it 
in  a  one  to  twenty  solution  of  carbolic  acid.  When  applied  to  the 
granulating  surface  it  is  first  cut  into  a  thin  piece  of  the  exact  shape 
of  the  opening  to  be  filled,  and  after  careful  disinfection  of  the  ulcer 
and  its  surroundings  it  is  placed  in  position,  and  covered  with  anti- 
septic dressings,  which  will  require  frequent  renewal  on  account  of  the 
decomposition  which  usually  occurs.  After  a  few  days  the  granula- 
tions will  spring  up  and  fill  the  interstices  of  the  sponge,  finally 
reaching  the  surface,  and  the  sponge  will  be  buried  out  of  sight;  the 
process  of  covering  with  epidermis  will  then  begin.  The  sponge  is 
afterward  absorbed.      The  late  Dr.   William   H.   Atkinson,   of  New 


ULCERATION.  89 

York,  Brock,  of  St.  Louis,  and  others,  made  extensive  use  of  this 
method  of  healing  ulcers  of  the  mouth,  and  reproducing  tissue  lost  by 
accident  or  surgical  operations. 

Constitutional  Treatment. — The  constitutional  treatment  of  ulcers 
must  be  directed  to  the  systemic  condition  which  operated  as  the 
predisposing  cause  of  the  affection.  It  may  not  be  possible  in  all  cases 
to  determine  or  discover  the  evidence  of  a  general  disorder,  or  taint  of 
the  system,  but,  when  such  a  taint  can  be  detected,  appropriate  reme- 
dies must  be  administered  for  its  eradication.  Syphilis  will  require 
appropriate  specific  treatment  accompanied  with  tonics.  Tuberculosis 
will  require  rest,  change  of  climate,  and  remedies  which  will  build  up 
and  support  the  strength  of  the  patient.  Anemia  and  diabetes  are 
frequently  predisposing  causes  of  ulcer,  and  should  not  be  overlooked 
when  searching  for  a  constitutional  cause  for  the  ulceration.  Gouty 
affections  are  often  associated  with  vascular  changes  and  ulceration  of 
the  skin  and  pericemental  tissue.  This  condition  should  be  sought 
for,  and,  if  present,  measures  must  be  taken  to  improve  the  general 
condition,  such  as  vegetable  diet,  abstinence  from  wines  and  malt 
liquors,  etc.  In  many  cases  of  chronic  ulcers,  no  constitutional  pre- 
disposing or  other  cause  can  be  discovered,  and  nothing  remains  in 
the.  line  of  constitutional  treatment  beyond  the  observance  of  simple 
hygienic  rules  of  life,  the  administration  of  tonics,  and  change  of  sur- 
roundings. 


CHAPTER    IX. 
NECROSIS,  CARIES,  AND  GANGRENE. 

Necrosis,  Caries,  and  Gangrene  are  conditions,  not  diseases. 

These  forms  of  death  occurring  in  tissues  and  organs,  and  in 
cells  and  cell  groups,  are  termed  local  death,  or  necrosis,  in  contra- 
distinction to  somatic  death,  or  death  of  the  whole  organism.  The 
causes  which  lead  to  local  death  of  tissues  may  be  divided  into  three 
groups.  The  first  includes  those  which  destroy  the  tissues  by  me- 
chanical or  chemical  action ;  for  instance,  external  violence,  which  may 
crush  a  finger  or  a  toe;  sulfuric  acid  or  caustic  potash,  which  may 
destroy  a  patch  of  skin;  or  micro-organisms,  which  may  disorganize 
the  structure  of  a  gland  to  which  they  have  gained  access.  The 
second  group  of  injuries  may  be  classed  as  thermal,  and  are  dependent 
upon  high  or  low  degrees  of  temperature.  If  the  temperature  of  the 
tissue  be  raised  to  130°  F.,  or  140°  F.,  and  maintained  at  that  degree 
for  any  length  of  time,  death  of  the  tissue  is  the  inevitable  result. 
Higher  temperatures  act  still  more  rapidly.  The  lower  limit  within 
which  the  life  of  tissues  may  be  maintained  for  any  considerable  period 
is  60°  to  64°  F.  (Ziegler.)  The  third  group  are  those  which  arise 
from  arrestation  of  the  circulation  and  nutrient  functions.  All  condi- 
tions which  seriously  interfere  with  the  circulation  so  as  to  bring  about 
stasis,  such  as  inflammation,  hemorrhage,  extravasation,  pressure 
upon  the  tissues,  thrombosis,  embolism,  or  closure  of  the  vessels  by 
disease  or  ligation,  may  lead  to  death  of  the  afifected  tissue.  It  is 
possible  for  all  three  of  these  groups  to  act  together  or  successively. 

The  effect  upon  the  tissues  of  a  given  injury  in  producing  local 
death  will  depend  upon  the  condition  of  the  tissues  at  the  time  of  the 
injury,  their  power  of  resistance,  and  the  condition  of  the  general 
organism.  Tissues  which  have  been  the  seat  of  a  pre-existing  in- 
flammation, or  any  other  condition  which  has  lowered  their  powers  of 
vital  resistance,  succumb  more  readily  to  injuries  which  produce 
necrosis,  caries,  and  gangrene  than  normal  tissues.  When  through 
disease  the  vital  powers  of  the  general  system  have  been  reduced, 
slight  injuries  will  often  cause  serious  consequences.  In  persons  suf- 
fering from  uncompensated  valvular  disease  of  the  heart,  slight  injury 
may  induce  gangrene  of  the  limbs.  In  patients  emaciated  from 
90 


NECROSIS,    CARIES,    AND   GANGRENE.  9I 

typhoid  fever,  slight  pressure  upon  the  skin  over  the  trochanter,  elbow, 
sacrum,  or  heels  may  induce  mortification  of  the  skin  and  subcutan- 
eous tissues. 

It  is  interesting  to  note  the  time  required  to  produce  death  in  the 
various  tissues  of  the  body  by  the  arrestation  of  the  blood-current. 
The  period  varies  in  different  tissues.  Brain-tissue,  renal  epithelium, 
and  intestinal  epithelium  die  in  two  hours.  Skin,  bone,  and  connec- 
tive tissue  continue  to  live  over  twelve  hours.  (Cohnheim.)  Tissues 
which  exercise  special  functions  die  more  quickly  than  those  which  do 
not  exercise  such  functions.  These  facts  should  govern  all  operations 
for  the  transplantation  or  replantation  of  tissues.  Success  is  more 
likely  to  crown  the  effort  in  transplanting  and  replanting  of  teeth  if 
the  operation  is  completed  within  an  hour  or  two  after  the  extraction 
of  the  tooth. 

Necrosis. 

Definition. — Necrosis  (from  the  Greek  veKp6<;,  dead). 

Necrosis  is  death  en  masse  of  bone-tissue. 

The  term  necrosis  signifies  the  condition  of  death.  When  used 
in  its  "technical  sense,  it  refers  to  the  process  of  death,  or  "the  sum  of 
the  actions  which  terminate  in  the  death  of  a  portion  of  the  skeleton, 
osseous  or  cartilaginous."  (Markoe.)  It  is  evident,  therefore,  that 
the  term  does  not  stand  for  a  particular  disease,  but  for  a  condition  or 
result  following  many  forms  of  disease  associated  with  the  bone.  It 
has  become  common  practice,  however,  with  surgeons  and  patholo- 
gists to  use  the  term  applied  to  this  condition  or  symptom  as  the  one 
most  convenient  and  best  suited  to  designate  the  affection  of  which  it 
is  at  most  only  an  accidental  consequence,  and  yet  one  that  is  very 
prone  to  occur  as  a  result  of  certain  injuries  and  diseased  conditions 
affecting  the  bones  or  the  tissues  immediately  connected  with  them. 
The  degree  of  injury,  whether  traumatic  or  idiopathic,  necessary  to 
cause  necrosis  of  bone,  is  much  less  than  is  required  to  produce  death 
of  the  soft  tissues.  This  may  be  explained  by  the  fact  that  the  exter- 
nal or  superficial  layers  of  the  bone  are  supplied  with  blood  through 
numberless  small  vessels  given  off  from  the  deeper  portions  of  the 
periosteum.  Separation  of  the  periosteum  from  the  bone  is  very  liable 
to  occur,  and  may  be  brought  about  in  various  ways;  for  example,  it 
may  be  stripped  from  the  bone  by  violence,  either  accidental  or  surgi- 
cal; it  may  be  lifted  from  its  attachment  by  effusion  of  blood,  resulting 
from  injury,  or  from  the  effusion  of  serum  or  other  inflammatory 
product,  especially  pus.  Another  reason  which  may  be  advanced  to 
account  for  the  readiness  with  which  bone-tissue  succumbs  to  inflam- 
matory processes  is  found  in  the  compact  tissue  of  the  bone  itself. 
"The  Haversian  canals  are  filled  completely  by  the  vessels  which  run 
into  them,  and  by  the  cell  structures  which  are  packed  tightly  around 


92  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

these  vessels,  so  that  when  the  inflammatory  stimuhis  calls  for  larger 
blood-currents  and  more  blood-cells,  there  is  no  room  for  the  enlarge- 
ment of  vessels  thus  imperatively  demanded,  and  the  consequence  is 
that  the  vessels,  not  having  the  power  to  accommodate  themselves  to 
this  new  and  sudden  demand,  become  choked,  stasis  occurs,  and,  as  a 
consequence,  those  portions  of  the  bone  most  deeply  involved  die." 
(Markoe.)  Death  of  dentine  occurs  in  the  same  manner  by  strangula- 
tion of  the  dental  pulp.  In  speaking  of  local  death  of  tissue,  the 
devitalized  portion  of  bone  is  called  a  sequestrum,  the  dead  portion  of 
soft  tissue  is  called  a  slough.  These  considerations  very  naturally  lead 
up  to  and  suggest  the  causes  of  necrosis. 

Causes. — Necrosis  or  death  of  bone-tissue  is  the  result  of  condi- 
tions which  have  impaired  or  entirely  arrested  the  supply  of  blood  to 
the  part,  like  traumatisms,  inflammatory  conditions  resulting  from 
syphilis,  mercurial  ptyalism,  poisoning  from  phosphorus  or  other 
toxic  substances,  extensive  inflammation  from  neighboring  parts,  or 
any  other  cause  w'hich  produces  a  lowered  vitality  of  the  tissues. 
Death  of  the  bone  may  be  confined  to  small  portions,  or  it  may  in- 
volve an  entire  bone.  Fragments  of  bone  w^hich  have  lost  their  vas- 
cular connection  may  also  become  the  seat  of  necrosis.  Fractures,  and 
periostitis  the  result  of  specific  infection,  or  the  constitutional  effects 
of  certain  drugs,  are  the  most  frequent  causes  of  necrosis.  Plate  I  is 
a  Roentgen-ray  picture  of  necrosis  of  the  tibia,  following  a  gunshot 
injury  to  a  soldier.  It  will  be  noticed  that  callus  has  formed  upon  one 
side  of  the  bone,  while  upon  the  other  a  sequestrum  of  necrosed  bone 
is  forming. 

The  dead  portion  of  bone,  when  not  already  separated  from  the 
living  tissues,  later  becomes  detached  in  consequence  of  the  formation 
of  granulation-tissue  between  the  dead  and  living  portions,  and  even- 
tually the  disintegration  of  this  tissue  leaves  the  necrosed  portion  sep- 
arated. The  process  of  separation  is  generally  slow  and  tedious,  and 
if  the  necrosed  part  is  deeply  situated  its  exfoliation  may  be  long  de- 
layed. The  structure  of  the  dead  portion  is  still  preserved,  so  that 
there  is  no  difficulty  in  its  recognition.  Suppuration  is  always  present, 
and  around  the  necrosed  bone  there  is  an  accumulation  of  a  fetid, 
purulent  fluid,  containing  broken-down  tissue,  debris  the  result  of 
decomposition  and  of  the  inflammatory  process,  which  by  degrees 
burrows  the  tissues,  and  eventually  reaches  the  surface.  A  sequestrum 
of  necrosed  bone  is  porous,  and  somewhat  lighter  than  living  bone, 
owing  to  the  fact  that  the  organic  elements  have  been  removed  from  it 
by  the  process  of  decomposition  and  the  action  of  the  granulation- 
tissues  which  surrounded  it. 

The  treatment  of  necrosis  and  caries  will  be  considered  in  the 
chapter  on  Necrosis  of  the  Jaws. 


NECROSIS,    CARIES,    AND    GANGRENE. 


93 


Cu 


necrosis,  caries,  and  gangrene.  95 

Caries. 

Definition. — Caries  (Lat.  caries,  rottenness). 

A  chronic  inflammation  of  bone,  with  rarefaction  or  absorption  of 
bone-tissue,  followed  usually  by  pus  formation;  molecular  death  of 
bone,  with  the  accompanying  process;  sometimes  termed  ulceration  of 
the  bone. 

The  term  caries  is  applied  to  a  molecular  death  and  disintegration 
of  bone-tissue.  The  two  forms  of  death  of  bone — necrosis  and  caries 
— are  to  the  osseous  tissue  what  gangrene  and  ulceration  are  to  the 
soft  tissues.  Necrosis  and  caries  of  bone  may  be  distinguished  clin- 
ically from  each  other  by  the  difiference  in  the  sound  given  ofT  when 
percussed  (the  percussion  note),  and  by  the  difference  in  the  degree  of 
density.  Upon  probing  the  opening  in  the  external  tissues  for  necrosed 
bone,  it  will  be  recognized  by  its  hardness  and  the  sharp  percussion 
note  when  struck  with  an  instrument,  while  caries  of  bone  will  give  a 
dull  sound  and  will  permit  the  penetration  of  the  instrument  into  its 
structure. 

Causes. — Caries  of  bone  is  a  chronic  inflammatory  condition,  in- 
duced almost  always  by  tubercular  or  syphilitic  infection.  The  tuber- 
cular form  occurs  most  frequently  at  the  epiphyseal  ends  of  the  long 
bones,  in  the  bodies  of  the  vertebrae,  and  occasionally  in  the  bones  of 
the  face,  the  lower  jaw  most  frequently.  The  syphilitic  form  is  most 
commonly  seen  in  the  bones  of  the  nose  and  palate.  In  the  tuber- 
cular form  the  affection  usually  causes  the  formation  of  abscesses, 
which  may  burrow  and  open  at  some  distance  from  the  seat  of  a  tuber- 
cular disease.  Upon  exposing  the  diseased  portion  of  the  bone  it  will 
be  found  to  be  softened,  disintegrated,  while  portions  have  been  re- 
moved by  liquefaction  or  absorption,  leaving  a  cavity  of  greater  or  less 
extent,  the  surface  of  which  will  be  covered  by  granulation-tissue  and 
exuding  pus.  If  the  process  has  been  rapid,  small  spiculse  of  necrosed 
bone  will  be  found  entangled  in  the  granulations  or  mixed  with  the 
pus.  In  syphilitic  caries,  especially  of  the  bones  of  the  nose  and  palate, 
the  external  covering  of  the  bone  will  usually  have  disappeared  from 
ulceration,  leaving  a  granulating  surface,  discharging  the  character- 
istic gummy  pus. 

Gangrene. 

Definition. — Gangrene  (Gr.ydyypaLva,  a  sore,  andy/oatmv,  to  gnaw). 

Mortification  or  death  of  a  part  of  the  body  from  failure  in  nutri- 
tion ;  death  en  masse  of  soft  tissue.  The  putrefactive  fermentation  of  a 
dead  limb  or  tissue. 

Gangrene  presents  itself  in  two  forms.  The  first  is  designated  as 
dry  or  senile  gangrene;  the  other  as  moist  gangrene. 

One  of  the  first  changes  which  takes  place  in  the  tissues  after  the 
death  of  the  part  is  the  disappearance  of  the  nuclei  of  the  cells.     In 


96  SURGERY    OF    THE    FACE,    JMOUTH,    AND    JAWS. 

some  cases  the  nuclei  become  granular,  probably  from  the  breaking  up 
of  the  chromatin — the  delicate  reticular  structure  of  the  nuclei — or  the 
material  which  is  most  susceptible  to  staining  agents,  and  passes  from 
the  nucleus  into  the  protoplasm  or  body  of  the  cells,  where  it  is  dis- 
solved and  disappears.  In  other  cases  the  nucleus  itself  seems  to  lose 
its  susceptibility  to  the  staining  fluids,  is  dissolved,  and  disappears. 
These  changes  take  place  after  closure  of  a  vessel  by  embolism,  and 
are  readily  seen  in  the  epithelium  of  the  kidneys  under  such  circum- 
stances. The  color  of  the  tissue  of  the  organ  is  also  changed  to  a 
pale,  cloudy,  yellowish-white  appearance,     (Warren.) 

"Coagulation-necrosis"  (Weigert)  may  sometimes  take  place,  and 
the  cellular  elements  be  transformed  into  granular  or  hyaline  masses, 
with  loss  of  their  nuclei.  Hyaline  degeneration  (a  conversion  of  tissue 
to  a  clear,  transparent,  jelly-like  material)  often  attacks  the  inter- 
cellular structure  of  the  tissues.  This  change  is  seen  in  muscle  fiber 
when  death  has  taken  place  from  toxic  infection,  a  burn,  or  other 
trauma. 

Death  of  tissue  accompanied  by  coagulation  occurs  in  two  ways. 
One  kind  occurs  in  certain  of  the  vital  fluids  like  the  blood  and  lymph, 
and  in  fluids  which  have  escaped  from  the  vessels,  by  the  formation  of 
granular,  fibrous,  or  homogeneous  coagula.  In  the  other,  cells  and 
intercellular  structures,  as  they  die,  become  solid  and  firm,  and  form 
by  coalescence  peculiar  homogeneous  or  hyaline  masses.     (Ziegler.) 

The  coagulation  of  blood  or  of  lymph,  according  to  current  opin- 
ion, occurs  when  the  white  blood-corpuscles  die  and  are  dissolved  in 
the  plasma,  and  the  granular,  fibrous,  and  hyaline  masses  which  appear 
are  albuminoid  in  character,  and  are  designated  in  general  terms  as 
fibrin.  To  bring  about  coagulation, — in  other  words,  the  formation  of 
fibrin, — the  presence  of  fibrinoplastin  (a  native  proteid  obtained  from 
the  blood-serum)  and  a  ferment  is  necessary.  Both  of  these  substances 
are  supplied  by  the  white  blood-cells  as  they  die  and  are  dissolved  in 
the  plasma.  Inflammatory  exudates  and  effusions  may  coagulate  in 
the  same  manner,  forming  masses  which  are  rich  in  fibrin.  False 
membranes  are  formed  in  this  way  upon  the  surfaces  of  inflamed  tissue. 

In  the  second  form  of  death  of  tissues,  the  circumstances  and 
appearances  are  essentially  different  from  those  of  the  first.  Coagula- 
tion of  the  albuminoids  has  taken  place  in  this  form  as  in  the  other, 
but  with  this  difference,  that  the  coagulation  has  occurred  in  the 
substance  of  the  formed  tissue  elements,  the  cells  and  intercellular 
substance,  instead  of  in  a  fluid.  It  is  necessary,  however,  in  order 
to  produce  this  form  of  coagulation,  that  a  moderate  amount  of 
lymph  shall  flow  through  the  dead  portion  of  tissue.  The  lymph  con- 
tains fibrinogen,  the  cells  fibrino-plastin,  and  by  a  combination  of 
these  substances  fibrin  is  produced,  resulting  in  coagulation-necrosis. 


NECROSIS^    CARIES,    AND   GANGRENE.  97 

Coagulation  of  the  dead  cells  is  not  so  likely  to  occur  in  tissues  in 
which  the  process  of  death  has  been  protracted,  for  the  reason  that 
degenerative  changes  may  be  established,  like  fatty  degeneration,  and 
thus  render  the  cells  non-coagulative.  Similar  cell  changes  to  those 
which  occur  in  coagulation-necrosis,  and  particularly  the  loss  of  the 
nuclei,  may  result  from  the  process  of  putrefaction. 

Causes. — Gangrene  is  so  intimately  associated  with  certain  changes 
in  the  arterial  system  that  it  will  be  necessary  to  mention  some  of 
the  conditions  which  are  liable  to  produce  it.  Among  the  most  fre- 
quent of  these  conditions  is  inflammation  of  the  walls  of  the  arteries.. 
Arteritis  is  almost  always  followed  by  the  production  of  new  tissue 
within  the  walls  of  the  vessel,  and  this  holds  an  important  relationship 
to  the  degree  of  freedom  with  which  the  blood  circulates  through  the 
diseased  vessels.  In  the  aorta  and  large  arteries,  this  new  formation 
assumes  the  form  of  warty  or  pediculated  projections,  which  in  the 
smaller  arteries  may  involve  them  for  a  considerable  distance,  and  be 
so  extensive  as  to  more  or  less  completely  close  the  lumen  or  caliber 
of  the  vessel,  and  this  condition,  termed  ''obliterating  endarteritis'^ 
(Warren),  may  greatly  impede  the  flow  of  blood  or  arrest  it  altogether. 

Atheromatous  degeneration  is  a  not  infrequent  termination  of 
many  cases  of  inflammation.  It  begins  in  this  particular  form  by  the 
formation  upon  the  inner  wall  of  the  vessel  of  soft,  gelatinous  nodules, 
which  after  a  time  become  quite  hard,  but  later  show  signs  of  degenera- 
tion, and  upon  cutting  them  open  they  are  found  to  contain  masses  of 
whitish  or  yellowish  material.  These  masses  finally  soften,  resulting- 
in  atheromatous  ulcers,  or,  according  to  Orth,  if  the  mass  be  seated 
deeper  in  the  wall  of  the  vessel,  a  cavity  may  be  formed  contain- 
ing fatty  granules,  fragments  of  tissue,  etc.,  forming  an  "atheromatous- 
abscess,"  which  may  eventually  discharge  its  contents  into  the  interior 
of  the  vessel.  Thrombi  sometimes  form  at  the  location  of  these  ab- 
scess cavities  or  open  ulcers.  In  the  smaller  vessels,  these  ulcers  may 
result  in  a  complete  obliteration  of  the  lumen  of  the  vessel.  Calci- 
fication sometimes  takes  place  in  the  atheromatous  foci,  and  these 
masses,  covered  with  epithelium,  may  be  present  in  large  numbers  in 
the  aorta  and  large  arteries,  or  they  may  be  found  projecting  from 
atheromatous  ulcers.  Syphilis  and  tuberculosis  also  produce  changes  in 
the  walls  of  the  arteries  which  impair  their  function  of  nutrition.  The 
effect  of  these  changes  coming  late  in  life  must  be  very  great  upon  the 
arterial  circulation  of  the  extremities,  as  there  is  naturally  at  this  time 
an  enfeeblement  of  the  circulation  in  these  localities.  If  the  disease 
has  been  confined  to  the  smaller  vessels,  the  circulation  has  been  grad- 
ually diminished,  and  finally  ceases,  as  the  result  of  the  formation  of  a 
small  thrombus,  or  of  some  insignificant  traumatism.  The  obliteration 
of  the  lumen  of  the  artery  cuts  ofif  all  fluid  from  the  dead  part,  and.  as 

8 


98  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

the  disease  has  not  been  connected  with  the  veins,  they  have  been 
unobstructed,  and  have  carried  off  the  venous  blood  in  the  part;  con- 
sequently the  dead  tissue  becomes  dried  from  evaporation,  and  the 
condition  is  produced  which  is  known  as  dry  or  senile  gangrene. 

When  death  of  a  portion  of  the  soft  tissue  takes  place,  there  is 
always,  as  a  constant  result,  a  more  or  less  severe  inflammation  in  the 
surrounding  part,  which  is  most  severe  when  decomposition  has  taken 
place  in  the  dead  portion.  Decomposition  is  due  to  the  action  of  the 
saprophytic  germs.  By  means  of  this  surrounding  inflammation — 
the  inflammatory  zone — the  dead  portion  is  dififerentiated  and  isolated 
from  the  rest.  The  inflammation  is  therefore  described  as  definitive, 
and  the  zone  as  the  line  of  demarkation. 

The  final  terminations  of  death  of  soft  tissues  are  generally 
classed  under  four  main  types.  In  the  first  class,  the  dead  tissue  is 
thrown  off  or  absorbed,  and  replaced  by  newly-formed  tissue  of  the 
same  character — normal  tissue :  this  is  termed  healing  by  regeneration. 

In  the  second  the  dead  tissue  is  likewise  thrown  off  or  absorbed, 
but  is  not  replaced  by  tissue  of  the  same  character,  but  by  a  fibrous 
tissue,  which  fills  up  the  gap  in  part  or  in  whole.  This  is  termed 
healing  by  scar  or  cicatrix. 

In  the  third,  the  dead  tissue  is  only  partially  absorbed,  a  portion 
remaining  as  a  caseous  mass,  which  later  may  become  calcified,  and 
inclosed  in  a  capsule  of  connective  tissue.  This  is  termed  caseation 
and  calcification. 

In  the  fourth,  the  dead  tissues  are  also  absorbed,  and  in  their  place 
there  is  developed  over  the  boundary  of  the  vacated  space  a  small 
amount  of  fibrous  tissue.  In  other  instances  this  space  becomes  filled 
with  fluid,  which  is  thus  encysted.  This  is  termed  encystment. 
(Ziegler.)  Examples  of  this  not  infrequently  occur  in  connection 
with  severe  pericementitis  and  alveolar  abscesses. 

Dry  Gangrene  or  Mummification. — This  condition  is  usually  the 
result  of  death  of  soft  tissue  in  parts  which  are  exposed  to  the  air,  and 
is  caused  by  defective  blood-supply  from  the  general  feebleness  of  the 
circulation,  and  local  changes  in  the  vessels  themselves.  Examples 
are  senile  gangrene  of  the  toes  and  the  feet.  The  affected  part  be- 
comes engorged  with  blood  before  its  death  takes  place,  and  the  color- 
ing matter  transudes  the  tissues,  and  gives  rise  to  a  dark  red  or  purple 
appearance.  At  the  same  time,  the  tissues  begin  to  dry  from  evapora- 
tion. The  part  first  becomes  leathery,  then  perfectly  hard,  brittle,  and 
black.  Between  the  dead  and  the  sound  tissues  there  is  always  the 
inflammatory  zone,  or  line  of  demarkation.  Dry  gangrene  is  often  an 
aseptic  gangrene.  This  form  of  gangrene  is  not  usually  attended  with 
any  general  constitutional  symptoms.  Attempts  to  remove  the  dead 
tissue  should  be  postDoned  until  separation  takes  place. 


NECROSIS,    CARIES,    AND   GANGRENE.  99 

Moist  Gangrene. — This  is  death  of  soft  tissue,  followed  by  decom- 
position and  putrefaction,  which  is  brought  about  by  the  presence 
of  micro-organisms.  These  organisms  may  reach  the  part  either 
through  the  air  or  through  the  circulation.  The  putrefying  tissue 
takes  on  the  characteristic  odor  of  putrid  animal  matter,  disintegrates, 
and  liquefies.  Not  infrequently  gases  are  formed  in  the  tissues  during 
the  process  of  disintegration,  causing  puffiness  of  the  part,  which  crep- 
itates under  pressure.  This  is  termed  emphysematous  gangrene.  The 
condition  is  sometimes  associated  with  alveolar  abscess  or  severe 
crushing  injuries  of  the  soft  tissues  of  the  face,  or  it  may  result  from 
ligating  the  facial  artery,  or  by  septic  poisoning.  Moist  gangrene  is 
necessarily  a  progressive  gangrene. 

Symptoms. — The  local  symptoms  are  at  first  acute  inflammation, 
with  great  congestion,  and  pain  of  an  intense  burning  character. 
Later  the  pain  ceases,  followed  by  loss  of  sensation  and  of  power  to 
move  the  part.  The  local  temperature  falls  below  normal,  and  pulsa- 
tion in  the  arteries  cannot  be  detected.  The  color,  which  at  first  was 
dusky  red,  gradually  assumes  a  blue,  purple,  dirty  brown,  or  black. 
Occasionally  blebs  are  formed,  and  the  superficial  vessels  are  marked 
by  lines  of  dark  discoloration.  Vitality,  even  at  this  stage,  is  not 
absolutely  destroyed,  and  may  still  be  restored;  but  if  the  cuticle  sep- 
arates from  the  derma,  and  can  be  removed  by  lightly  rubbing  the 
part,  and  if  there  are  crepitation,  emphysema,  and  foul  odor,  there  can 
no  longer  be  doubt  of  the  absolute  death  of  the  part. 

The  constitutional  symptoms  of  gangrene  are  those  of  inflamma- 
tory fever  of  low  type,  with  rapid,  feeble  pulse,  and  low  delirium. 

Prognosis. — The  prognosis  must  be  based  upon  the  etiology,  the 
location,  the  extent  of  the  disease  which  caused  the  gangrene,  and  the 
general  condition  of  the  patient. 

An  acute,  rapidly-spreading  gangrene,  especially  of  the  face  and 
head,  should  always  be  considered  as  an  exceedingly  grave  condition. 
The  danger  arises  from  the  introduction  into  the  general  circulation 
of  soluble  toxic  substances  or  ptomaines. 

When  the  gangrene  is  of  mycotic  origin,  and  rapidly  progressive 
in  its  character, — with  or  without  emphysema, — it  almost  without  ex- 
ception proves  fatal,  unless  early  and  heroic  treatment  has  been  insti- 
tuted. Death  results  from  septicemia  through  the  introduction  of  pus- 
microbes  or  putrefactive  bacteria. 

Noma  {cancer  aquaticus) ,  gangrana  oris,  or  gangrenous  ulceration 
■of  the  cheek,  is  characterized  by  an  exceedingly  rapid  destruction  of 
the  tissues.  Very  little  is  known  of  its  etiology.  Its  favorite  primary 
seat  is  the  mucous  membrane  of  the  cheek,  generally  at  some  distance 
from  the  lips,  and  most  often  at  the  junction  of  the  cheek  with  the 
gums ;  more  frequently  at  the  inferior  gingivo-buccal  fold  than  at  the 


lOO  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

superior  fold.  It  is  generally  confined  to  one  side  of  the  face.  On  this 
account,  some  have  thought  it  to  be  caused  by  a  disturbance  of  the 
nervous  system.  It  is  more  likely  to  be  of  mycotic  origin.  No  specific 
micro-organism  has  yet  been  found  in  noma.  Lingard  found  long 
bacilli,  and  Ranke  has  found  streptococci.  Various  other  forms  have 
been  discovered,  but  their  relations  have  not  been  determined. 

It  attacks  exclusively  little  children  between  the  ages  of  two  and 
eight  years,  who  have  been  poorly  nourished,  or  are  suffering  from 
one  of  the  eruptive  fevers,  typhus,  or  are  of  cachectic  habit.  It  is 
rarely  seen  in  this  country  except  in  districts  the  most  unsanitary,  but 
it  is  quite  common  in  the  large  cities  of  Europe  among  the  very  poor. 

The  disease  often  spreads  very  rapidly,  quickly  destroying  the 
entire  cheek.  It  is  not,  however,  confined  to  the  soft  tissues,  but  at- 
tacks the  maxillary  bones,  often  causing  extensive  necrosis  and  loss  of 
the  teeth.  The  disease  generally  proves  fatal  in  a  few  days.  In  one 
case  which  came  under  the  notice  of  the  writer  at  St.  Luke's  Hospital, 
the  patient  lived  but  five  days;  another  just  one  week. 

Dry  gangrene  does  not  therefore  present  the  serious  conditions 
of  the  moist  varieties,  as  it  is  not  attended  with  the  same  dangers  of 
septic  intoxication. 

Hospital  gangrene  only  occurs  as  an  infection  of  wounds,  and  is 
seldom  found  outside  of  unsanitary  and  overcrowded  hospitals.  Before 
the  introduction  of  antiseptic  surgery  it  was  quite  common,  especially 
in  the  military  hospitals  of  Europe,  and  in  our  own  during  the  War  of 
the  Rebellion. 

Billroth  believed  the  disease  was  due  to  a  specific  micro- 
organism, which  is  only  produced  under  certain  atmospheric  condi- 
tions; hence  its  epidemic  form.  There  is  no  doubt  that  the  disease  is 
often  carried  from  one  patient  to  another  by  the  sponges,  instruments,, 
the  hands  of  the  operators  and  nurses,  and  in  the  atmosphere. 

The  fact  that  this  terrible  disease  has  been  stamped  out  of  the 
oldest  and  most  unsanitary  hospitals  by  the  strict  antiseptic  treatment 
of  wounds,  would  seem  to  be  conclusive  evidence  that  it  is  of  mycotic 
origin. 

Treatment. — All  patients  suffering  from  gangrene  are  in  a  debili- 
tated condition,  either  from  antecedent  or  concomitant  causes,  and  are 
consequently  unfavorably  affected  by  the  so-called  antiphlogistic  or 
sedative  treatment. 

Fever  is  always  the  result  of  septic  elements  which  have  gained  an 
entrance  into  the  system;  antipyretics  are  therefore  not  indicated,  but 
effort  should  be  made  to  remove  the  primary  cause  of  the  infection. 
This  is  the  most  important  point  in  the  whole  line  of  treatment. 

The  strength  of  the  patient  must  be  supported  from  the  very  be- 
ginning, by  a  generous  diet  and  the  use  of  stimulants.     In  case  of 


NECROSIS,    CARIES,    AND    GANGRENE.  lOI 

feeble  heart-action,  dig-italis  is  administered  with  benefit.  The  bitter 
tonics  are  often  beneficial  in  improving  the  appetite. 

In  all  cases  of  gangrene  of  the  face  and  oral  cavity,  the  removal  of 
the  dead  tissues  should  be  accomplished  just  as  soon  as  the  line  of 
demarkation  has  been  established,  not  waiting  for  complete  separation 
to  take  place.  The  partially  separated  tissue  may  be  removed  by  the 
scissors  and  the  curette,  after  which  the  wound  resulting  from  such 
treatment  may  be  cared  for  upon  antiseptic  principles. 

In  cases  of  emphysematous  gangrene,  the  gases  and  fluid  should 
be  evacuated  just  as  soon  as  their  presence  is  established,  by  numerous 
small  incisions  made  over  the  affected  area,  care  being  taken  not  to 
injure  important  blood-vessels.  Good  drainage  must  be  established 
and  maintained  so  long  as  discharges  are  present. 

The  most  favorable  symptom  after  operation  in  cases  with  septic 
intoxication  is  a  reduction  of  the  temperature  within  a  few  hours  to 
the  normal  point.  The  removal  of  the  tissue  which  had  caused  the 
septic  poisoning,  and  the  elimination  of  these  toxic  substances  from  the 
system  through  the  excretory  organs,  produces  a  subsidence  of  the 
constitutional  symptoms,  and  if  the  patient  has  sufficient  strength  to 
carry  him  through  the  shock  of  the  operation,  he  has  good  prospects 
of  an  ultimate  recovery. 

In  noma  and  hospital  gangrene,  after  the  removal  of  the  dead 
tissue  with  the  scissors  and  curette,  and  thorough  irrigation,  the  sur- 
faces of  the  wound  should  be  seared  with  the  electro-thermal  cautery. 
Dr.  W.  C.  Cahall  reports  a  case  of  noma  in  a  child  seven  years  of  age 
suffering  from  typhoid  fever  that  was  successfully  treated ;  after  cauter- 
ization, curretting  and  an  extensive  cutting  operation  had  failed ;  by 
the  injection  of  lo  c.c.  of  antistreptococcus  serum.  In  twelve  hours 
a  line  of  demarkation  formed,  and  within  twenty-four  hours  the 
gangrenous  part  had  disappeared,  leaving  a  healthy-looking  wound. 
Antiseptic  conditions  should  be  maintained  in  the  after-treatment. 
This  will  be  found  to  be  somewhat  difificult  of  accomplishment  when 
the  disease  is  associated  with  the  oral  cavity;  but  with  care  and  per- 
sistent effort  much  may  be  done  in  this  direction.  Thiersch  solution 
and  boric  acid  solution  are  valuable  antiseptics,  and  may  be  used  with 
impunity  in  the  oral  cavity,  without  fear  of  toxic  symptoms. 


CHAPTER   X. 
TRAUMATIC   INFLAMMATORY   FEVER. 

Definition. — Traumatic  fever  is  a  reactive  fever  following  shock 
from  injury  or  operation. 

In  shock  following  injury  the  temperature  falls  below  the  normal; 
when  reaction  sets  in  the  temperature  rises  above  the  normal.  As  a 
general  rule,  the  greater  the  shock  the  lower  the  temperature,  and 
when  reaction  sets  in  the  reactive  temperature  will  be  correspondingly 
high.  The  fever  usually  develops  a  few  hours  after  the  injury,  and 
generally  subsides  in  from  twenty-four  to  forty-eight  hours. 

Traumatic  fever  may  be  aseptic  or  septic,  the  character  depending 
upon  the  condition  which  prevailed  at  the  time  of  the  injury. 

Aseptic  fever  is  a  condition  which  accompanies  the  healing  of 
wounds  by  first  intention.  An  elevation  of  temperature  from  two  to 
three  degrees  frequently  accompanies  the  healing  of  wounds  which 
have  been  treated  antiseptically,  but  in  which  there  is  the  formation  of 
a  considerable  blood-clot  between  the  Hps  of  the  wound,  or  in  those 
cases  where  the  bruising  and  manipulation  of  the  tissues  has  been 
extensive.  Attention  has  already  been  called  to  the  fact  that  cer- 
tain chemical  substances  of  a  non-pyogenic  nature  were  capable  of 
causing  a  rise  in  the  temperature  when  introduced  into  the  circulation. 
Among  these  substances  is  a  peculiar  ferment,  obtained  from  defibri- 
nated  blood,  known  as  ''fibrin- ferment."  This  substance,  when  in- 
jected into  animals,  causes  extensive  coagulation  of  the  blood,  and 
death.  The  animal  alkaloids  or  leucomaines  produced  by  the  construc- 
tive metabolism  of  the  tissues  which  occurs  in  the  healing  of  wounds  are 
not  unlikely  active  factors  in  the  production  of  this  form  of  fever.  On 
the  other  hand,  the  leucomaines  produced  by  the  destructive  metabo- 
lism, which  takes  place  in  minute  portions  of  tissue,  and  in  blood-clots 
remaining  between  the  lips  of  wounds,  may  produce  a  like  result. 

In  aseptic  fever,  the  only  symptom'  of  marked  character  is  the 
elevation  of  the  body  temperature.  This  may  reach  102°  or  even 
104°,  and  not  entirely  disappear  for  several  days.  Patients  suffering 
from  this  form  of  fever  are  rarely  conscious  of  feeling  unwell,  and  may 
be  able  to  sit  up  in  bed,  or  even  move  about  the  room.  (Warren.) 
The  conditions  under  which  this  form  of  fever  is  most  commonly  seen 


TRAUMATIC    INFLAMMATORY    FEVER.  IO3 

are  in  deep  and  extensive  wounds  which  are  healing  by  first  intention; 
in  wounds  closed  without  drainage;  in  simple  fractures  of  the  bones, 
and  other  subcutaneous  injuries. 

Septic  fever  was  supposed,  before  the  introduction  of  antiseptic 
surgery,  to  be  a  natural  consequence  of  the  process  of  repair,  as  all 
wounds  healed  with  more  or  less  inflammation,  even  though  suppura- 
tion was  not  established.  The  constitutional  symptom  of  fever,  which 
was  sometimes  very  considerable,  was  called  surgical  or  traumatic 
fever.  We  now  know  that  these  conditions  were  due  to  the  presence 
of  micro-organisms  in  the  exudations  of  such  wounds,  which  produced 
fermentative  changes  or  decomposition,  with  the  elaboration  of  pto- 
maines, the  absorption  of  which  caused  an  elevation  of  body  tempera- 
ture or  fever,  by  their  poisonous  effects  upon  the  system. 

This  type  of  fever  is  often  seen  to-day  following  wounds  which 
have  not  been  treated  antiseptically,  and  in  those  injuries  which  have 
been  exposed  to  infection,  or  in  which  infective  material  has  been  intro- 
duced. Examination  of  the  blood  taken  from  patients  suffering  from 
this  type  of  fever  reveals  but  few  bacteria  in  this  fluid,  and  when  they 
are  present  rapid  elimination  or  destruction  takes  place,  so  that  they 
may  entirely  disappear  in  the  course  of  two  or  three  days.  Progres- 
sive development  of  micro-organisms  in  the  blood  never  takes  place  in 
this  form  of  fever  as  it  does  in  septicemia.  A  rigor  followed  by  a 
sudden  elevation  of  temperature,  occurring  on  the  first  or  second  day 
after  the  injury,  is  indicative  of  septic  poisoning  and  the  formation  of 
pus.  A  sudden  fall  of  temperature,  with  a  weak  pulse,  occurring  at  the 
same  period,  would  indicate  shock  from  internal  hemorrhage,  or 
collapse. 

Septic  fever  occurring  in  these  days  of  antiseptic  surgery  is  an 
evidence  of  either  a  slovenly  operation;  of  deep-seated,  penetrating  or 
tortuous  wounds,  impossible  to  cleanse;  wounds  involving  the  peri- 
toneum, and  of  compound  fractures  of  the  bone  in  locations  impossible 
to  keep  thoroughly  clean  ;  as,  for  instance,  in  compound  fractures  of  the 
maxillary  bones  of  individuals  who  give  no  thought  to  the  cleanliness  of 
their  mouths ;  or  of  infection  of  wounds  by  septic  instruments,  especially 
in  the  extraction  of  teeth.  This  form  of  fever  generally  appears  on  the 
second  or  third  day  after  the  injury  or  the  infection,  and  lasts  from 
two  to  six  days. 

The  constitutional  symptoms  are  a  sudden  rise  of  temperature, 
100°  to  102°  F.,  skin  hot  and  dry,  the  pulse  rapid,  and  the  tongue 
coated,  accompanied  with  delirium  or  with  digestive  disturbances, 
heat,  restlessness,  and  thirst.  The  urine  is  scanty  and  high  colored, 
the  bowels  often  constipated.  The  character  of  the  evening  tempera- 
ture is  progressive.  On  the  evening  of  the  second  day  it  miay  be  ioi°, 
the  next  morning  drop  one  or  two  degrees,  to  again  rise  in  the  evening 


I04  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

to  1 02°,  while  on  the  fourth  day  it  may  reach  103°.  These  signs  of 
constitutional  irritation  would  certainly  point  to  the  presence  of 
decomposition  in  the  exuded  material,  the  establishment  of  the  suppu- 
rative process,  or  some  form  of  infective  inflammation.  If  suppuration 
takes  place,  pus  is  formed  on  the  third  or  fourth  day.  The  wound  then 
cleans  oflf,  the  ptomaines  are  washed  away  with  the  discharges,  granu- 
lations spring  up,  and  the  system  regains  its  normal  temperature. 

Traumatic  fever,  suppurative  fever,  septicemia,  and  pyemia  are  all 
dependent  upon  the  same  causes,  and  are  of  the  same  nature,  the  only 
difiference  between  them  being  one  of  degree.  The  symptoms,  how- 
ever, are  somewhat  different. 

Suppurative  fever,  or  "secondary  fever,"  as  it  is  sometimes  called, 
is  dependent  upon  the  suppurative  process,  and  is  therefore  a  septic 
fever.  It  is,  however,  different  from  traumatic  or  surgical  fever,  for  in 
this  form  the  temperature  falls  as  soon  as  pus  is  formed.  Suppurative 
fever  appears  two  or  three  days  after  the  injury,  and  generally  subsides 
at  the  end  of  the  first  week;  but  if  the  fever  continues  beyond  this 
period,  or  if  at  the  beginning  of  the  second  week  there  should  be  a 
sudden  rise  of  temperature,  with  or  without  a  rigor,  this  would  be  a 
good  reason  for  suspecting  the  presence  of  pus  at  the  point  of  injury. 
If  the  injury  is  at  a  point  inaccessible  to  drainage,  or  difficult  to  reach 
with  antiseptics,  the  high  temperature  will  correspond  in  degree  with 
the  severity  of  the  suppurative  process;  while  on  the  other  hand,  if  the 
pu?  can  be  reached  and  evacuated,  and  the  wound  treated  antisep- 
tically,  the  temperature  will  soon  subside  and  the  general  febrile 
symptoms  disappear. 

It  more  commonly  happens,  however,  when  the  infective  inflam- 
mation is  of  an  acute  form,  that  the  character  of  the  fever  will  be  of  the 
continued  type,  with  frequent  exacerbations.  The  local  symptoms, 
under  proper  treatment,  become  less  acute,  and  eventually,  as  in  joint 
and  bone  diseases,  numerous  sinuses  are  formed,  communicating  with 
the  seat  of  suppuration,  and  from  which  pus  freely  discharges,  thus 
establishing  chronic  suppuration.  From  this  time  forward  the  fever 
assumes  the  remittent  type  of  suppurative  fever,  which  consists  of  a 
normal  or  subnormal  temperature  in  the  morning,  followed  by  a  rise 
of  from  two  to  as  high  as  six  degrees  in  the  afternoon,  and  accom- 
panied by  the  hectic  flush  and  other  signs  of  febrile  disturbances.  If 
the  suppurative  process  is  not  checked,  there  will  be  considerable  loss 
of  flesh,  great  prostration,  diarrhea,  and  profuse  perspiration  at  night. 
Emaciation  is  progressive,  bed-sores  are  developed,  and  the  strength 
of  the  patient  gradually  fails,  until  it  becomes  only  a  question  of  how 
long  the  physical  endurance  will  hold  out.     (Warren.) 

In  chronic  suppuration  resulting  from  tubercular  disease  this  form 
of  fever  may  continue  for  months,  with  increasing  but  more  gradual 


TRAUMATIC    INFLAMMATORY    FEVER.  IO5 

emaciation;  and  when  death  occurs,  post-mortem  examination  of  the 
internal  organs  shows  extensive  amyloid  degeneration.  These  facts 
prove  conclusively  that  the  temperature  is  due  to  the  continued  absorp- 
tion of  chemical  substances  elaborated  in  the  wound  by  a  destructive 
metabolism,  or  by  the  presence  of  the  pus-producing  micro-organisms. 
The  clinical  evidence  of  this  lies  in  the  fact  already  indicated,  namely: 
That  as  soon  as  the  supply  of  the  pyogenic  material  is  cut  off  by  thor- 
ough drainage  and  antiseptic  treatment,  the  febrile  symptoms  dis- 
appear. 

Suppurative  fever  of  long  continuance,  if  accompanied  with  great 
emaciation  and  prostration,  would  be  a  contra-indication  for  a  severe 
surgical  operation,  as  in  all  probability  there  would  exist  extensive 
amyloid  degeneration  of  the  internal  organs. 

Treatment. — The  local  treatment  of  traumatic  inflammatory  fever 
consists  of  freeing  the  wound  of  all  tension,  providing  against  the  pos- 
sibility of  the  retention  of  the  inflammatory  discharges,  irrigating  thor- 
oughly with  germicidal  solutions,  covering  the  wound  with  boric  acid 
or  iodoform,  and  the  use  of  sterilized  dressings,  changed  every  day  or 
twice  a  day  if  necessary. 

The  constitutional  treatment  would  be  to  clear  the  bowels  by 
means  of  a  saline  cathartic,  control  the  temperature  with  aconite  or  the 
antipyretic  drugs;  the  pain  by  the  use  of  morphia,  and  nervous  excite- 
ment with  bromid  of  potassium. 

The  treatment  of  suppurative  fever  of  either  the  acute  or  chronic 
type  consists  in  the  establishment  of  thorough  drainage,  and  of  disin- 
fection of  the  entire  suppurating  surface.  To  accomplish  this  the  pus 
cavity  must  be  laid  open  by  free  incisions,  and  its  walls  thoroughly 
scraped  with  the  curette.  After  the  infective  material  has  been  scraped 
away  the  wound  may  be  cleansed  with  antiseptic  solutions,  followed 
by  peroxid  of  hydrogen,  and  again  irrigated  with  the  carbolic  or 
bichlorid  solution.  When  joints  are  diseased,  amputation  frequently 
offers  a  better  chance  of  saving  life  than  by  resecting  the  joint. 

The  constitutional  treatment  should  consist  of  free  stimulation,  a 
nutritious  diet,  and  tonics.  Out-of-door  life,  if  practicable,  will  many 
times  bring  about  a  decided  improvement  in  the  conditions.  If  the 
affection  is  the  result  of  tuberculosis,  the  prognosis  is  most  unfav- 
orable. 


CHAPTER    XL 

SEPTICEMIA. 

Definition. — Septicemia  (from  the  Greek  o-i^Trrds,  putrid,  and  at/xa 
blood). 

Septicemia  is  a  disease  or  condition  induced  by  the  absorption  of 
septic  products;  a  form  of  blood-poisoning. 

Two  forms  of  septic  fever  are  still  to  be  considered,  viz:  Septi- 
cemia and  pyemia.  Both  of  these  conditions  have  been  recognized 
ever  since  their  description  by  Hippocrates,  and  on  account  of  their 
dangerous  and  often  fatal  character  have  always  been  the  subjects  of 
anxious  thought  and  investigation.  Since  the  promulgation  of  the 
germ  theory  of  disease,  investigation  and  experimental  research  into 
the  cause  of  these  diseases  have  been  greatly  stimulated,  and  though  it 
may  not  be  said  with  positive  assurance  what  the  actual  cause  may  be, 
yet  such  advancement  has  been  made  as  to  make  it  almost  certain  that 
they  are  due  to  the  action  of  the  micro-organisms  of  putrefaction,  the 
saprophytic  germs.  Antiseptic  surgery  has  here  won  another  signal 
victory  by  preventing  the  development  of  these  grave  conditions,. 
thereby  saving  thousands  of  lives  that  would  otherwise  have  perished. 
Both  of  these  conditions,  however,  are  still  occasionally  seen  in  hos- 
pital wards  where  thorough  antisepsis  has  been  neglected  or  has  failed 
on  account  of  the  peculiar  character  of  the  wound,  which  has  rendered 
it  impossible  to  carry  out  the  most  approved  methods ;  or  by  reason  of 
the  severity  of  the  injury  to  the  tissues,  which  has  resulted  in  gangrene 
and  sloughing. 

Billroth  said,  in  speaking  of  these  diseases,  that  septicemia  bears 
the  same  relationship  to  surgical  or  traumatic  fever  that  pyemia  bears 
to  suppurative  fever,  each  being  the  malignant  type  of  the  correspond- 
ing milder  affection. 

Surgical  fever,  as  already  stated,  is  developed  in  the  earlier  stages 
of  the  process  of  repair  in  wounds,  before  the  establishment  of  the 
suppurative  process,  by  the  absorption  of  ptomaines  elaborated  in  the 
wounded  tissues  as  a  result  of  putrefaction;  the  fever  subsides  upon 
the  formation  of  pus,  which  cleanses  the  wound  and  prevents  further 
absorption  by  washing  away  the  pyogenic  substances.     (Warren.) 

Septicemia  is  also  dependent  upon  septic  infection  of  the  wound, 

1 06 


SEPTICEMIA.  107 

the  absorption  of  poisonous  substances  resulting  from  decomposition, 
which  produces  a  profound  impression  upon  the  system,  and  often 
terminates  fatally.  The  disease  is  therefore  a  malignant  form  of  putrid 
infection,  and  is  a  sequel  of  a  grave  type  of  surgical  or  traumatic  fever. 
It  is  seen  most  frequently  as  a  complication  of  amputation  wounds, 
severe  crushing  injuries,  compound  fractures  of  the  long  bones  and  of 
the  lower  jaw,  acute  osteomyelitis,  deep  tortuous  wounds  which  it  is 
impossible  to  treat  by  thorough  antisepsis,  gangrenous  conditions  of 
the  tissues,  wounds  of  the  peritoneum,  and  in  obstetrical  cases  from  the 
retention  and  decomposition  of  blood-clots  or  placental  debris  within 
the  uterus.  It  most  often  occurs  in  wounds  in  which  the  discharges 
are  abundant;  the  septic  micro-organisms  have  had  free  access,  and  the 
process  of  putrefaction  has  been  established. 

The  disease  is  characterized  by  serious  constitutional  disturbances, 
such  as  high  temperature,  great  prostration,  disorders  of  the  nervous 
system,  inflammatory  conditions  of  certain  internal  organs,  accom- 
panied by  typhoid  symptoms  and  a  tendency  to  heart-failure. 

Causes. — The  nature  of  the  toxic  element  which  produces  the  dis- 
ease is  not  yet  fully  demonstrated,  but  it  is  generally  accepted  to  be  a 
product  of  the  process  of  putrefaction,  either  in  the  form  of  ptomaines 
which  are  absorbed  by  the  system;  the  introduction  into  the  body  and 
tissues  of  certain  forms  of  micro-organisms  which  rapidly  grow  and 
multiply;  or  possibly  of  the  introduction  of  some  "ferment-like  sub- 
stances" having  the  power  of  reproduction,  and  acting  within  the  or- 
ganism like  the  poison  of  serpents,  the  virus  of  tetanus  or  of  diph- 
theria.    (Warren.) 

By  experimentation  upon  animals  it  has  been  demonstrated  that 
there  are  two  varieties  of  septicemia, — one  the  result  of  poisoning  by 
a  chemical  substance,  and  the  other  by  the  presence  of  bacteria  in  the 
blood.  The  first  is  termed  sapremia,  toxemia,  or  septic  intoxication. 
The  second  is  termed  mycosis  or  septic  infection.  In  the  first  the  symp- 
toms begin  immediately  upon  the  injection  of  the  poison  into  the  tis- 
sues, their  intensity  being  governed  by  the  size  and  the  virulence  of  the 
dose,  while  in  the  second  form  the  disease  is  developed  after  an  inter- 
val, probably  dependent  upon  the  rapidity  of  the  development  and  the 
multiplication  of  the  bacteria  in  the  blood,  but  progressing  uninter- 
ruptedly to  a  fatal  termination. 

Koch  could  not  discover  a  constant  bacterium  in  septicemia,  and 
therefore  concluded  that  those  which  were  found  in  the  blood  were 
not  the  specific  organism  of  the  disease.  The  forms  of  bacteria 
usually  found  in  septicemia  in  man  are  the  staphylococci  and  the 
streptococci.  Micro-organisms  are,  however,  by  no  means  always 
present  in  the  blood  in  septicemia.  Rosenbach  found  that  blood-cul- 
tures taken  from  septicemia  in  man  proved  sterile.     In  these  cases. 


I08  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

however,  he  found  the  staphylococci  present  in  the  blood.  He  there- 
fore comes  to  the  conclusion  that  the  disease  in  man  is  usually  the 
result  of  the  absorption  of  ptomaines  or  ferments,  and  not  of  an  inva- 
sion of  the  blood  by  a  specific  micro-organism.  Besser  takes  just  the 
opposite  view,  and  believes  the  disease  is  produced  solely  by  the 
streptococcus. 

Clinically,  the  two  forms  of  the  disease  just  mentioned  are  also 
found  in  the  human  species.  In  the  former  there  is  an  early  absorption 
of  the  products  of  putrefaction,  but  the  symptoms,  as  soon  as  further 
absorption  of  the  poisonous  substances  is  prevented  by  draining-  and 
cleansing  the  wound,  rapidly  disappear.  In  the  latter  the  symptoms 
develop  more  slowly,  and  there  are  progressive  changes  established 
which  often  continue  to  a  fatal  termination  in  spite  of  all  efforts  by 
antiseptic  treatment  of  the  wound.  This  form  is  doubtless  due  to  the 
presence  of  micro-organisms  in  the  blood,  although  their  demon- 
stration is  not  always  possible.  Gussenbauer  thinks  that  there  is  fre- 
quently a  mixture  of  these  two  types  of  the  disease. 

Avenues  of  Infection. — The  avenues  through  which  infection  may 
enter  the  system  are:  septic  wounds,  accompanied  by  gangrene  and 
sloughing;  this  is  the  most  common  mode  of  infection,  though  the 
disease  may  appear  in  its  malignant  form  from  even  a  very  slight  and 
insignificant  wound,  in  which  the  putrefactive  process  has  been  estab- 
lished, or  bacteria  have  multiplied  and  been  diffused  through  the 
system.  Septic  infection  sometimes  accompanies  other  traumatic 
infective  diseases,  like  erysipelas  and  hospital  gangrene.  Infection 
may  also  take  place  through  the  mucous  membrane  of  the  intestinal 
tract.  The  intestinal  canal  is  always  loaded  with  the  various  micro- 
organisms of  disease,  and  under  favorable  conditions  represented  by 
enfeebled  health  they  may  gain  access  to  the  tissues  and  blood,  and,  as 
pointed  out  by  Cheyne,  a  local  injury  or  inflammation  may  furnish  the 
proper  soil  for  the  development  and  multiplication  of  these  wandering 
bacteria,  and  thus  an  infective  inflammation  will  be  established,  fol- 
lowed by  general  infection  of  the  system. 

The  genito-urinary  tract,  when  in  a  normal  condition,  is  rarely  an 
avenue  through  which  infection  takes  place.  The  uterus  immediately 
following  parturition  is  a  quite  common  avenue  of  infection,  and  many 
lives  have  heretofore  been  lost  through  ignorance  of  or  an  imperfect 
knowledge  of  this  fact.  The  respiratory  mucous  membrane  is  gen- 
erally considered  to  be  proof  against  the  entrance  of  putrefactive  infec- 
tion, as  is  also  the  skin,  when  it  is  in  a  normal  condition.  Fig.  35  is  a 
culture  from  "Sputum  septicemia,"  Bronchitis  piitrida,  or  fetid  bron- 
chitis resulting  from  gangrene  of  portions  of  the  lung. 

Sapremia. — Sapremia,  or  the  toxic  form  of  septicemia,  is  most 
frequently  observed  in  obstetrical  wards  and  lying-in  hospitals,  and  is 


SEPTICEMIA. 


log 


due  to  putrefaction  of  blood-clots  and  fragments  of  placenta  retained 
in  the  uterus.  Infection  takes  place  by  absorption  of  the  poison 
through  the  mucous  membrane  of  the  vagina  or  the  uterus;  through 
abrasions  or  lacerations  of  the  vagina  or  cervix  uteri;  at  the  point  of 
attachment  of  the  placenta  with  the  uterus,  or  directly  into  the  circu- 
lation through  the  uterine  sinuses. 

Symptoms. — The  disease  is  ushered  in  by  a  sharp  and  sudden 
rise  of  temperature,  ioi°  to  103°  F.,  but  rarely  higher.  The  chill 
which  usually  precedes  the  onset  of  other  acute  affections  is  com- 
monly absent.     The  parts  which  are  chiefly  attacked  by  the  poison  are 

Fig.  35. 


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Micrococcus  of  Sputum  Septicemia.    X  looo. 

the  blood,  the  nervous  system,  and  the  intestinal  canal.  The  changes 
in  the  blood  are  marked,  causing  anemia,  while  the  inflammatory  con- 
dition of  the  intestinal  canal  is  doubtless  due,  in  part  at  least,  to  the 
efforts  of  nature  to  eliminate  the  poison.  The  temperature  remains 
high,  and  is  accompanied  later  by  delirium.  The  skin  is  cold  and 
clammy,  and  coma  supervenes  in  the  fatal  cases. 

In  surgery  it  rarely  happens  that  conditions  favorable  to  the  de- 
velopment of  this  form  of  blood-poisoning  occur.  It  is  seen  occa- 
sionally, however,  in  large  wounds  which  have  not  been  provided  with 
proper  means  of  drainage  for  the  escape  of  the  blood  and  serum;  in 
the  presence  of  gangrenous  and  sloughing  tissues;  in  psoas  or  other 
deep-seated  abscesses  from  putrefaction  of  their  contents,  or  in  wounds 
of  the  peritoneum  followed  by  the  formation  of  blood-clots  within  the 


110  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

abdominal  cavity  and  their  decomposition.  The  results  of  treatment 
in  this  type  of  the  disease  are  usually  very  striking  and  satisfactory, 
as  the  prompt  removal  of  the  decomposing  material  contained  in  the 
uterus,  under  antiseptic  conditions,  is  followed  in  a  few  hours  by  a 
lowering  of  the  temperature  and  a  disappearance  of  the  alarming 
symptoms.  The  same  is  true  of  the  treatment  of  those  conditions 
which  are  purely  surgical  in  their  nature;  the  removal  of  the  putrefying 
substances,  accompanied  by  thorough  antiseptic  treatment  of  the 
wound,  is  generally  followed  by  the  most  gratifying  results. 

Symptoms  of  Septicemia. — Septic  infection,  or  true  septicemia, 
does  not  differ  materially,  in  its  early  constitutional  symptoms,  from 
those  just  described.  The  principal  difference  exists  in  the  more  grad- 
ual development  of  the  disease,  and  the  interval  which  occurs  before 
the  multiplication  of  the  micro-organisms  or  the  elaboration  of  the 
poison  is  made  manifest.  The  fever  is  of  the  continuous  type,  like  that 
in  sapremia,  but  in  the  malignant  form  of  the  disease,  as  the  fatal 
termination  approaches,  the  temperature  will  run  higher,  ranging 
from  103°  to  106°  F.,  and  may  suddenly  fall  to  normal  or  below. 

A  sub-normal  temperature  is  sometimes  observed  in  cases  result- 
ing from  strangulated  hernia,  gunshot  wounds  of  the  abdomen,  and 
occasionally  following  operations  for  the  removal  of  abdominal  tumors. 
The  pulse  is  soft,  rapid,  becoming  weak  and  thready,  and  easily  com- 
pressible. The  respirations  are  rapid  and  shallow.  Great  prostration, 
accompanied  by  headache,  loss  of  appetite,  and  thirst,  are  the  usual 
symptoms.  Later  the  patient  becomes  apathetic  and  indiflferent  to  sur- 
roundings; diarrhea  and  vomiting  are  frequently  developed.  Enlarge- 
ment of  the  spleen  and  lymphatic  glands  throughout  the  body  is  a 
characteristic  of  the  disease.  The  skin  takes  on  a  pale,  dusky  hue,  and 
the  conjunctivae  are  tinged  a  faint  yellow,  though  this  condition  is  not 
so  marked  as  in  pyemia.  Examinations  of  the  blood  during  life  show 
a  breaking  down  of  the  red  blood-corpuscles,  an  increase  in  the 
number  of  leucocytes,  and  the  presence  of  micrococci.  Scarlet  erup- 
tions sometimes  occur,  resembling  the  rash  of  scarlet  fever.  The  skin, 
which  in  the  earlier  stages  of  the  disease  was  hot  and  dry,  later  is 
bathed  in  perspiration,  and  finally  becomes  cold  and  clammy.  The 
tongue  is  dry,  hard,  and  coated  brown;  the  teeth  are  covered  with 
sordes.  The  expression  becomes  listless  and  indifferent.  The  diar- 
rhea increases,  the  stools  are  offensive,  and  the  urine  becomes  con- 
centrated and  scanty  in  amount.  The  feces  and  urine  may  be  passed 
involuntarily.  Delirium  follows  the  stupor,  coma  is  developed,  and 
death  takes  place  in  collapse. 

Diagnosis. — The  diagnostic  signs  of  the  disease  would  be  the  high 
continued  fever,  with  absence  of  chills,  the  listlessness  and  indifference 
of  the  patient,  and  the  general  disturbance  of  the  alimentary  canal,  as 


SEPTICEMIA.  Ill 

constitutional  symptoms.  An  increased  area  of  dullness  in  the  region 
of  the  spleen,  the  presence  of  albumin  and  micro-organisms  in  the 
urine,  would  be  further  aids  to  diagnosis,  as  would  also  a  septic  con- 
dition of  the  wound.  There  are  no  very  marked  or  characteristic 
signs  in  this  disease  to  guide  in  the  diagnosis,  and  the  surgeon  must 
therefore  depend  upon  the  general  appearance  of  the  patient,  and  his 
ability  to  reach  a  diagnosis  by  the  process  of  exclusion. 

Prognosis. — The  prognosis  of  this  disease  is  always  grave.  When 
the  disease  is  caused  by  septic  intoxication  (sapremia),  it  is  much  more 
favorable  than  when  the  result  of  septic  infection  (mycosis).  In 
the  former,  when  of  a  pure  type,  the  removal  of  the  decomposing 
material  is  usually  followed  by  a  subsidence  of  the  constitutional 
symptoms,  but  inasmuch  as  the  surgeon  can  never  be  quite  sure  that 
the  disease  is  not  of  a  mixed  type,  the  opinion  must  be  a  guarded  one. 

When  the  disease  is  the  result  of  acute  septic  infection,  the  prog- 
nosis is  exceedingly  unfavorable,  as  it  is  one  of  the  most  fatal  of  dis- 
eases. The  chronic  form  of  the  disease  gives  a  little  more  hope  of  a 
favorable  termination,  although  a  majority  of  this  class  of  cases  finally 
end  in  death. 

Treatment. — The  treatment  must  be  both  local  and  constitutional. 
Prophylactic  treatment  consists  principally  in  establishing  aseptic  con- 
ditions of  the  wound  and  the  surroundings,  by  a  strict  application  of 
the  principles  of  antiseptic  surgery.  As  soon  as  the  diagnosis  of  septi- 
cemia is  made,  the  attention  of  the  surgeon  should  be  at  once  directed 
to  the  condition  of  the  wound,  and  the  most  thorough  measures  of 
disinfection  inaugurated,  compatible  with  the  strength  of  the  patient. 
The  wound  must  be  opened  by  removing  the  stitches,  and  all  stitch- 
sinuses  fully  exposed,  and  free  drainage  established  for  the  putrefying 
discharges.  Irrigation  of  the  wound  with  bichlorid  of  mercury  solu- 
tion, I  to  looo;  carbolic  acid  solution,  i  to  20,  or  peroxid  of  hydrogen 
in  moderate  quantity  for  the  purpose  of  disinfection,  is  of  prime  im- 
portance before  applying  the  dressings.  In  certain  cases  it  will  be 
necessary  to  curette  the  surface  of  the  wound  in  order  that  the  disin- 
fecting fluid  may  reach  the  deeper  portions  of  the  tissues,  and  thus 
hasten  the  expulsion  of  the  invading  micro-organisms.  The  wound 
may  then  be  packed  with  iodoform  or  boric  acid  gauze,  or  hot  anti- 
septic fomentations  may  be  applied  to  stimulate  a  free  drainage. 

In  sapremia,  free  irrigation  of  the  wound  with  antiseptic  solutions 
is  frequently  followed  by  an  immediate  relief  of  the  symptoms.  Wash- 
ing of  the  uterus  in  puerperal  fever  gives  a  like  result. 

The  constitutional  treatment  should  be  directed  to  the  elimination 
of  the  ptomaines  taken  up  by  the  circulation,  which  may  be  accom- 
plished by  a  free  saline  purgative;  and  to  sustaining  the  strength  of  the 
patient  and  his  resistance  to  the  effects  of  the  poison.     Reliance  must 


112  SURGERY    OF    THE    FACE,    MOUTH,    AND   JAWS. 

therefore  be  placed  upon  nourishment  and  alcoholic  stimulants.  The 
form  of  nourishment  must  be  suited  to  the  condition  of  the  digestive 
system,  and  is  best  administered  in  small  quantities  and  frequently. 
Large  quantities  of  alcohol  can  be  consumed  by  a  patient  suffering 
from  this  disease  without  producing  alcoholism. 

The  use  of  antipyretic  drugs  for  the  control  of  the  fever  does  not 
give  very  satisfactory  results,  and  is  therefore  not  recommended  by 
many  of  our  best  surgeons. 

Heart-failure  should  be  guarded  against  by  the  use  of  heart- 
tonics.  The  tincture  of  digitalis,  in  doses  of  5  to  10  drops,  is  of  great 
value  in  this  direction.  Strychnia  in  doses  of  gr.  1-40  to  1-30  every 
two  to  six  hours,  is  one  of  the  best.  The  diarrhea  can  be  treated  by 
opium,  or  bismuth  and  tannin. 


CHAPTER    XII. 
PYEMIA. 

Definition. — Pyemia  (from  the  Greek  7rT;"v,  pus,  and  at/xa,  blood). 

Pyemia  is  a  phlebitic  or  sanguiferous  septicemia,  with  the  pres- 
ence of  pyogenic  micro-organisms  in  the  blood,  and  the  formation  of 
metastatic  abscesses  as  a  result  of  the  localization  of  the  micro-organ- 
isms in  remote  portions  of  the  body. 

Pyemia  or  septic  fever  is  an  infectious  disease,  termed  by  Velpeau 
a  purulent  infection,  developed  during  the  process  of  suppuration  in 
wounds  or  the  formation  of  abscesses,  and  is  due  to  the  presence  in 
the  blood  of  pyogenic  bacteria.  It  is  attended  with  the  formation  of 
multiple,  metastatic,  or  secondary  abscesses  in  various  portions  of  the 
body,  as  a  result  of  the  lodgment  of  the  micro-organisms  and  their 
development  into  colonies,  thus  establishing  independent  foci  of  sup- 
puration. The  same  form  of  micro-organism  is  found  in  the  secondary 
abscesses  that  are  present  in  the  wound  secretions.  (Senn.)  The 
disease  is  further  characterized  by  recurring  chills  and  fever,  of  an 
intermittent  type. 

The  disease  is  always  associated  with  suppuration,  and  is  in  reality 
a  complication  or  a  grave  constitutional  expression  of  that  affection. 
It  is  never  seen  before  suppuration  has  been  established. 

The  disease  was  well  known  and  correctly  described  by  the  ancient 
medical  writers.  The'  old  view  that  the  pus  found  in  the  wound 
was  absorbed  or  entered  the  blood-current  direct,  was  abandoned  long 
ago.  We  know,  however,  that  certain  elements  of  the  pus,  and  micro- 
organisms, do  gain  access  to  the  circulation,  and  by  their  lodgment 
cause  the  formation  of  thrombi,  which  finally,  on  breaking  up,  float 
away  in  the  blood-current,  and  produce  embolism  by  plugging  a  small 
vessel  in  some  distant  location  of  the  body,  and  thus  cause  the  forma- 
tion of  septic  infarcts  and  metastatic  abscesses. 

Predisposing  Causes. — All  suppurating  wounds,  especially  of 
bone,  are  predisposing  causes  of  pyemia.  Among  those  which  pre- 
dispose to  metastatic  inflammations  are  contused  wounds,  wounds  of 
joints,  compound  fractures,  particularly  of  the  head,  abscesses  asso- 
ciated with  the  jaws,  osteomyelitis,  injuries  of  the  veins,  wounds  re- 
ceived by  individuals  in  a  low  state  of  vitality,  and  wounds  received 
in  war,  on  account  of  the  severe  shock  and  the  difficulties  in  the  way 

9  "3 


114  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

of  immediate  care  of  the  injured,  and  of  thorough  antiseptic  treatment 
upon  the  field.  The  disease  usually  makes  its  appearance  about  ten 
days  after  the  injury,  when  the  suppurative  process  is  at  its  height, 
though  it  may  begin  at  any  time  after  the  suppurative  process  has  been 
established. 

Climate. — Certain  seasons  of  the  year,  especially  the  early  spring, 
are  thought  to  predispose  to  the  disease,  as  the  conditions  of  the  at- 
mosphere at  this  time  seem  to  favor  the  more  rapid  growth  and  devel- 
opment of  the  pus-microbes. 

Age  and  Sex. — The  influence  of  age  and  sex  as  predisposing 
causes  is  of  considerable  importance.  Men  in  the  prime  of  life 
are  much  oftener  affected  with  the  disease  than  children  or  old  men, 
or  women  at  any  time  of  life.  The  greater  prevalence  of  the  dis- 
ease among  men  in  the  prime  of  life  is  doubtless  due  to  the  greater 
exposure  to  traumatisms  to  which  they  are  subjected;  to  the  diseases 
incident  to  advancing  years;  and  also  to  certain  conditions  of  the  sys- 
tem, such  as  diabetes  and  alcoholism,  which  render  the  system  pe- 
culiarly susceptible  to  the  influence  of  traumatisms. 

Active  Causes. — The  active  causes  of  the  disease  are  the  pus- 
microbes.  It  is  only  during  the  last  decade  that  the  bacterial  nature  of 
the  disease  has  been  satisfactorily  demonstrated  by  the  discovery  of  the 
pus-microbes — the  staphylococcus  and  streptococcus — in  the  blood  of 
patients  suffering  from  pyemia,  and  the  production  of  the  disease  by 
inoculating  animals  with  infected  tissue  and  blood.  Koch  produced 
the  disease  in  rabbits  by  injecting  into  the  subcutaneous  tissue  fluid 
obtained  from  decomposing  flesh.  From  the  heart  of  this  animal  he 
abstracted  blood  and  injected  it  into  another  rabbit,  and  again  pro- 
duced the  characteristic  metastatic  deposits.  In  the  blood-vessels  he 
found  chain-like  micrococci  which  were  adherent  to  the  walls  in  little 
masses;  each  mass  inclosing  several  blood-corpuscles.  The  micro- 
organisms seemed  to  possess  the  power  of  causing  adhesion  of  the 
blood-corpuscles  and  the  formation  of  thrombi.  He  was  not  able  to 
find  the  micrococci  in  the  lymphatics. 

Besser  examined  the  blood,  pus,  and  parenchymatous  fluids  of  23 
cases  of  pyemia,  and  found  the  staphylococcus  present  in  8  cases,  the 
streptococcus  in  14,  and  both  kinds  in  i.  He  also  collected  the  rec- 
ords of  46  cases,  and  out  of  these  he  found  the  staphylococcus  present 
22  times,  the  streptococcus  21  times,  and  both  in  3  cases.  He  thinks 
the  cocci  of  pus  and  the  cocci  of  pyemia  are  identical. 

Pawlowsky  is  of  the  opinion  that  the  staphylococcus  is  the  usual 
cause  of  the  disease.  The  data  presented  up  to  the  present  time  are 
not  sufliciently  conclusive  to  settle  the  question  of  the  particular  pyo- 
genic organism  which  causes  the  formation  of  the  metastatic  abscesses, 
for  both  the  staphylococcus  and  the  streptococcus  have  been  found  in 


PYEMIA. 


IIS 


the  disease  in  man,  but  the  proof  is  sufficient  to  estabHsh  the  pus- 
microbes  as  the  active  cause  of  the  disease. 

Infection  of  the  general  system  always  takes  place  from  a  suppur- 
ating wound  or  an  abscess,  and  the  avenues  through  which  the  infec- 
tion enters  the  system  are,  almost  without  exception,  the  blood-vessels. 
Occasionally,  however,  it  may  gain  an  entrance  through  the  lymphatic 
system. 

The  effect  of  the  micro-organisms  when  they  have  developed  in 
such  quantity  as  to  overwhelm  the  tissues  in  the  immediate  neighbor- 
hood of  the  wound  or  abscess,  is  to  cause  an  infective  inflammation  of 
the  walls  of  the  veins  with  which  they  come  in  contact,  with  the  result 
of  causing  a  thromho-phlebitis.  Nutritional  changes  take  place  in  the 
endothelium  as  a  result  of  the  inflammation,  and  rough  places  are 
formed  upon  the  inner  surface  of  the  vein.  Leucocytes  now  congre- 
gate at  the  roughened  places  and  become  adherent,  finally  forming 
homogeneous  masses,  and  thus  become  the  starting  point  of  a  throm- 
bus, which  may  increase  in  size,  and  more  or  less  completely  fill  the 
lumen  or  caliber  of  the  vessel.  The  red  corpuscles  also  collect  about 
these  rough  places,  and  materially  aid  the  process  of  forming  a  throm- 
bus. Eventually  the  thrombus  softens  and  breaks  down  as  a  result  of 
its  infection  with  the  micro-organisms  of  the  wound,  and  masses  are 
floated  away  in  the  blood-current  as  emboli,  or  a  zooglea  mass  of 
inicrococci  may  accumulate  upon  the  inner  wall  of  the  vein,  and  finally 
become  dislodged  and  carried  away  by  the  circulation,  to  be  deposited 
in  the  lungs,  where  they  form  fresh  foci  of  infection,  which  may  result 
in  the  formation  of  pulmonary  metastatic  abscesses. 

A  thrombus  is  a  clot  of  blood  formed  within  the  heart  or  blood- 
vessels during  life,  and  is  due  usually  to  some  impediment  to  the  circu- 
lation, or  to  alteration  in  the  blood  or  vessel-walls.  Thrombosis  is  the 
process  by  which  the  clot  is  formed. 

An  embolus  is  a  detached  thrombus,  or  part  of  a  thrombus,  a  clot 
of  blood,  or  other  foreign  substance,  brought  by  the  blood-current 
from  a  distant  artery,  and  forming  an  obstruction  at  its  place  of  lodg- 
ment. The  act  or  process  by  which  this  is  brought  about  is  termed 
embolism.  The  process  of  closing  or  plugging  an  artery  or  capillary 
by  an  embolus  is  called  infarction,  and  the  area  of  tissue  cut  ofif  from  its 
supply  of  blood  is  called  an  infarct.  The  shape  of  the  infarct  is  always 
that  of  a  wedge,  with  the  apex  at  the  point  of  lodgment  of  the  embolus, 
and  it  corresponds  in  size  to  the  caliber  and  distribution  of  the  vessel 
obstructed.  The  infarct  may  be  discovered  by  the  ischemia  of  the 
part  which  has  been  deprived  of  its  supply  of  blood. 

Thrombo-arteritis  also  occurs  from  penetration  of  the  walls  of  the 
arteries  by  the  micrococci,  but  on  account  of  the  greater  density  of  the 
-walls   and   rapidity   of  the   blood-current,   thrombosis   rarely   occurs. 


Il6  SURGERY    OF    THE    FACE,    MOUTH,    AXD   JAWS. 

When  thrombi  are  formed  in  the  arteries  the}'  are  not  of  such  serious 
consequence  as  when  developed  in  the  veins,  as  they  are  not  carried  to 
distant  organs,  but  when  detached  the  emboH  are  simply  deposited  in 
adjacent  capillary  regions.  Minute  emboli  and  micrococci  may  pass 
through  the  capillaries  of  the  lungs,  enter  the  pulmonary  vein,  the  left 
side  of  the  heart,  and  thus  be  carried  through  the  arterial  system  to 
remote  organs,  where  they  become  arrested  in  the  capillaries  and  favor 
the  development  of  metastatic  abscesses;  or  zooglea  masses  of  micro- 
cocci may  form  in  the  pulmonary  vein  and  result  in  the  development 
of  a  thrombus,  which  later  breaks  up  by  puriform.  softening  induced 
by  the  micrococci,  and  fragments  are  floated  away  to  cause  embolism 
in  the  capillaries  of  distant  organs. 

The  internal  organs  which  are  most  often  the  seat  of  metastatic 
abscesses  are  the  lungs,  liver,  kidneys,  spleen,  brain,  and  heart.  The 
lungs  are  the  most  common  location  of  these  abscesses.  Among  the 
important  complications  of  this  character  are  the  formation  of  sup- 
purative conditions  of  the  joints,  as  a  result  of  secondary  infection, 
and  phlegmonous  inflammations,  which  frequently  accompany  puer- 
peral pyemia.  The  parotid  gland  is  not  an  infrequent  seat  of  meta- 
static abscess. 

Pus,  as  a  rare  occurrence,  may  form  an  abscess  and  find  its  way 
into  the  circulation  through  absorption  or  necrosis  of  the  walls  of  the 
vein.  The  so-called  spontaneous  pyemia  occurs  by  means  of  an  inter- 
vascular  infection.  Micrococci  are  frequently  found  circulating  in  the 
blood  of  individuals  of  a  more  or  less  enfeebled  condition  of  health, 
and  under  such  circumstances  a  cold  or  trifling  wound,  a  bruise  or  an 
injury  occurring  to  a  bone  without  an  external  wound,  as,  for  instance, 
to  the  medulla  ossium  by  a  fall,  may  result  in  acute  symptoms  with  the 
development  of  an  osteomyelitis,  and  the  patient  eventually  dies  of 
pyemia. 

Single  organisms  would  be  very  unlikely  to  inaugurate  the  sup- 
purative process,  as  the  resistance  of  the  tissues  is  such  that  their 
pathogenic  action  would  soon  be  neutralized,  and  they  are  moreover 
quickly  eliminated  from  the  blood.  (Warren.)  It  only  seems  neces- 
sary, however,  in  certain  individuals,  that  the  tone  of  the  general 
system  should  be  somewhat  lowered,  or  that  there  shall  exist  at  some 
point  a  lack  of  normal  resistance  induced  by  disease  or  injury,  for  the 
rapid  development  and  localization  of  these  organisms  in  the  circula- 
tion to  take  place,  thus  overcoming  the  barriers  afforded  by  the  tissues 
against  their  growth  and  multiplication.  Such  localization  may 
become  the  starting  point  of  an  extensive  infection  of  the  system  with 
the  formation  of  metastatic  abscesses,  and  all  the  other  conditions  of 
pyemia.  Poore  has  reported  several  cases  of  chronic  pyemia  resulting 
from  alveolar  abscesses,  which  illustrate  the  danger  of  the  retention  of 


PYEMIA.  117 

small  accumulations  of  pus  under  certain  conditions  of  the  general 
health. 

Symptoms. — The  most  prominent  of  the  symptoms  of  pyemia  are 
the  chills,  which  are  severe  and  prolonged.  This  symptom  is  first 
made  manifest  usually  in  the  second  week  of  the  healing  process,  when 
suppuration  has  been  well  established.  It  is  usually  associated  with  a 
high  temperature,  104°  to  106°  F.,  soon  terminating  in  a  drenching 
perspiration,  the  temperature  quickly  falling  to  the  normal  or  below. 
The  fever  is  therefore  of  the  intermittent  type.  The  chills,  however, 
may  not  accompany  the  first  onset  of  the  fever,  while  in  other  cases 
the  chills  may  be  the  only  symptom  which  at  first  arrests  the  attention 
of  the  surgeon,  as  the  febrile  disturbance  has  been  but  slight.  The 
occurrence  of  a  rigor  during  the  healing  of  a  wound  should  always 
arouse  the  suspicion  of  the  surgeon,  and  cause  a  careful  inspection  of 
the  wound,  which  generally  reveals  a  local  infection,  and  symptoms  of 
an  infective  inflammation.  The  lips  of  the  wound  are  red  and  swollen, 
and  the  interior  will  present  a  characteristic  grayish,  sloughy  appear- 
ance. The  fever  is  of  an  irregular,  intermittent  type,  and  may  vary 
with  the  frequency  of  the  chills  or  possess  an  hourly  variation  of  its 
own.  Several  chills  may  occur  during  twenty-four  hours,  followed 
by  profuse  perspiration  and  fall  of  temperature.  The  recurrences, 
however,  are  very  irregular.  The  fever  dift'ers  from  all  other  forms  in 
not  haviilg  a  regular  evening  rise  and  morning  fall  of  the  temperature, 
and  is  characterized  by  a  series  of  sharp  rises  and  falls  during  the 
tvv^enty-four  hours. 

The  development  of  secondary  abscesses  is  indicated  by  febrile 
exacerbations  and  local  inflammatory  symptoms.  The  formation  of  an 
abscess  in  the  lung,  or  a  septic  pleuritic  effusion,  will  be  indicated  by 
pain  in  the  side  and  respiratory  disturbance.  Metastatic  abscesses  in 
the  liver  cannot  be  readily  recognized  unless  occurring  near  the  sur- 
face, when  a  peritonitis  will  be  developed,  and  its  presence  indicated 
by  sharp  pain  at  that  location.  Inflammatory  conditions  of  the  joints 
resulting  from  secondary  deposits  are  a  frequent  symptom  of  the  dis- 
ease, and  are  accompanied  by  considerable  swelling  of  the  surrounding 
soft  parts.  Swelling  of  the  parotid  gland,  with  the  formation  of  meta- 
static abscesses,  is  not  an  infrequent  symptom  of  the  disease.  The 
skin  becomes  icteric,  or  tinged  a  deep  yellow  hue.  With  this  discolor- 
ation of  the  skin  there  is  always  a  progressive  emaciation,  which  in 
chronic  cases  becomes  extreme.  The  breath  has  a  sweetish,  hay-like, 
purulent  odor.  The  pulse  becomes  weak,  rapid,  and  thready;  the 
strength  rapidly  fails.  The  tongue  is  dry  and  coated  brown,  the  gums 
and  teeth  are  covered  with  sordes.  A  scarlet  rash,  or  erythematous 
patches  appear,  which  have  a  tendency  to  form  pustules,  doubtless 
from  localization  of  the  micrococci,  which  later  may  coalesce  and  dis- 


Il8  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

charge  an  offensive  puriform  fluid.  The  mental  condition  of  the  indi- 
vidual is  generally  unafifected,  but  there  is  developed  as  a  marked 
symptom  a  general  hyperesthesia,  and  the  patient  complains  of  sharp 
pains  in  various  localities  of  the  body,  which  may  be  due  in  some 
cases  to  metastatic  abscesses,  and  in  others  to  hypersensitiveness  of 
the  nerves.  The  presence  of  an  infective  endocarditis  would  be  re- 
vealed by  the  heart-sounds.  The  spleen  is  not  so  often  affected  with 
enlargement  in  pyemia  as  it  is  in  septicemia.  The  kidneys  are  occa- 
sionally affected,  but  the  urine  affords  but  little  positive  information. 
Brain  symptoms  are  rarely  present,  though  metastatic  inflammations 
may  occur  and  hemiplegia  result  from  emboli  due  to  the  formation  of  a 
thrombus  in  the  left  side  of  the  heart.  The  duration  of  acute  pyemia 
is  from  ten  to  fifteen  days.  The  chronic  form  of  the  disease  may  run 
for  weeks  and  months.  In  the  later  stages  of  the  disease  the  mind 
fails,  delirium  sets  in,  followed  by  coma  and  death. 

Diagnosis. — The  diagnostic  signs  of  the  disease  are  repeated 
chills,  the  intermittent  type  of  the  fever,  excessive  diaphoresis,  emacia- 
tion, hyperesthesia,  and  great  prostration.  The  presence  of  meta- 
static abscesses  and  inflammatory  conditions  of  the  joints  would  con- 
firm the  diagnosis. 

Prognosis. — The  prognosis,  as  a  rule,  is  exceedingly  unfavorable 
in  the  acute  cases.  It  has  generally  been  considered  to  be  a  fatal 
disease,  though  undoubted  cases  of  recovery  are  on  record,  with  a  rela- 
tively higher  percentage  of  recoveries  from  puerperal  pyemia  than 
from  surgical  pyemia.  The  chronic  form  of  the  disease  is  more  likely 
to  terminate  favorably  than  the  acute  form.  Guerin  thinks  these 
patients  do  not  long  survive  their  recovery  from  the  disease. 

Treatment. — The  treatment  of  pyemia  is  for  the  most  part 
prophylactic,  and  this  consists  in  the  prevention  of  suppuration.  No 
more  brilliant  achievement  has  ever  been  obtained  in  any  department 
of  medicine  or  surgery  than  that  recorded  in  the  treatment  of  wounds 
by  aseptic  methods.  The  aseptic  treatment  of  wounds  has  almost 
entirely  abolished  pyemia  and  kindred  diseases  from  hospitals,  where, 
before  its  introduction,  they  were  of  common  occurrence.  The  first 
step  to  be  taken  upon  the  discovery  of  septic  disturbance  is  thorough 
and  complete  disinfection  of  the  wound,  after  which  the  surfaces  should 
be  curetted  for  a  sufficient  depth  to  remove  all  sloughing  and  putrefy- 
ing material,  not  only  of  the  wound  itself,  but  also  of  the  interior  of  the 
vein  through  which  the  infection  is  being  introduced  into  the  system. 
This  method  has  been  successfully  carried  out  by  Macewen  in  throm- 
bosis of  the  lateral  and  sigmoid  sinuses  following  suppuration  of  the 
middle  ear  and  of  the  mastoid  cells.  He  recommends  the  opening  of 
the  vein  and  the  removal  of  the  disintegrating  clot  with  a  small  spoon, 
and,  if  antiseptic  solutions  are  used  to  wash  out  the  debris,  care  must 


PYEMIA.  119 

be  taken  to  avoid  the  admission  of  air  into  the  vein.  Tying  of  the  vein 
is  recommended  by  others,  before  the  clot  is  removed,  as  a  further  pre- 
caution against  this  danger  and  also  to  prevent  the  further  passage  of 
septic  material  into  the  circulation.  The  ligature  must  be  placed  at  a 
point  between  the  wound,  the  point  of  primary  suppuration,  or  the 
puriform  thrombus  and  the  heart.  Amputation  of  a  limb  when  the 
point  of  infection  is  located  in  that  region  has  been  recommended. 
Warren  made  the  attempt  to  save  a  patient  by  this  method,  but  without 
success.  Several  cases  have  been  reported,  however,  of  favorable  re- 
sults. To  be  successful,  the  operation  must  be  done  early,  and  the 
surgeon  must  be  reasonably  sure  that  the  point  selected  for  the  opera- 
tion is  above  the  location  of  the  thrombus.  Metastatic  abscesses,  where 
accessible,  should  be  immediately  opened  and  disinfected.  The  same 
active  measures  should  be  employed  in  the  treatment  of  suppurating 
joints.  In  chronic  cases,  which  are  more  amenable,  such  treatment 
may  be  effective  in  saving  the  life  of  the  patient. 

The  constitutional  treatment  should  consist  mainly  of  easily- 
digested  and  nutritious  food,  given  in  as  large  quantities  as  the  patient 
can  appropriate,  and  alcoholic  stimulants,  administered  as  freely  as  the 
patient  can  bear.  The  use  of  antipyretic  drugs — the  coal-tar  deriva- 
tives— is  not  advisable,  as  most  of  them  have  a  depressing  effect  upon 
the  heart.  Quinin  in  large  doses  is  sometimes  advised.  Carbonate 
of  ammonium  and  digitalis  are  of  service  during  the  stage  of  prostra- 
tion. Hygienic  conditions  of  the  surroundings  of  the  patient  are  not 
to  be  overlooked;  good  ventilation  or  out-of-door  air,  if  the  patient 
can  be  moved  with  safety,  are  of  great  value  in  chronic  cases.  Patients 
in  hospitals,  with  pyemia,  should  be  isolated,  and  a  strict  quarantine 
maintained  over  the  nurses  in  attendance,  as  a  safeguard  against  the 
spread  of  the  disease. 

Pyemia  dependent  upon  alveolar  abscesses  demands  the  immedi- 
ate extraction  of  the  offending  teeth,  and  thorough  curetting  of  the 
abscess  cavity.  After  irrigation  with  antiseptic  solutions,  the  cavity 
should  be  packed  with  aseptic  gauze,  or  idoform  gauze,  and  the 
dressing  changed  twice  or  three  times  during  the  day,  until  a  healthy 
granulating  surface  is  established,  after  which  frequent  irrigation  with 
antiseptic  solutions  will  be  sufficient. 

The  constitutional  symptoms  should  be  treated  upon  the  lines 
already  indicated. 


CHAPTER    XIII. 
ERYSIPELAS. 

Definition. — Erysipelas  (from  two  Greek  words,  ipvOpo?,  red,  and 
TTeWa,  hide  or  skin).     Sometimes  called  St.  Anthony's  fire. 

Erysipelas  is  an  infectious  inflammation  which  primarily  affects 
the  skin. 

Erysipelas  is  one  of  the  most  common  traumatic  infective  dis- 
eases. It  is  a  constitutional,  specific,  infective  acute  inflammation  of 
rapidly-spreading  type,  affecting  the  skin,  and  occasionally  the  mucous 
and  serous  membranes.  It  is  attended  with  redness,  as  its  name  in- 
dicates, swelling,  often  with  considerable  serous  exudation,  some- 
times of  a  purulent  character,  and  manifested  in  the  form  of  edema, 
vesicles,  bullae,  pustules,  or  by  diffuse  suppuration,  and  occasionally,  in 
the  severer  types,  it  may  be  followed  by  gangrene  and  the  formation  of 
gas  in  the  cellular  tissues,  from  the  action  of  the  micro-organisms  of 
putrefaction. 

The  origin  of  the  disease  is  a  micro-organism,  the  Streptococcus 
erysipelatis,  a  bacterium  similar  to  the  pus  streptococcus. 

The  disease  is  characterized  by  a  marked  tendency  to  spread  at 
the  periphery.  There  is  no  longer  any  doubt  of  its  infectious  nature, 
as  the  experimental  proofs  upon  this  point  are  abundant,  while  some 
authorities  consider  it  to  be  not  only  infectious  but  decidedly  con- 
tagious. Clinical  proof  is  not  wanting  to  establish  this  fact  also. 
The  disease  being  of  microbic  origin,  the  infection  is  readily  carried 
upon  the  hands  of  the  surgeon  and  nurses,  upon  the  instruments, 
dressings,  towels,  bedding,  etc.  This  accounts  for  its  spread  in  the 
surgical  wards  of  hospitals,  and  for  the  infection  of  obstetrical  cases 
by  physicians  or  nurses  who  have  been  in  recent  contact  with  either 
of  the  various  forms  of  the  disease,  or  with  suppurating  wounds,  and 
thus  inducing  puerperal  fever.  It  is  one  of  those  diseases  which  have 
not  been  entirely  eradicated  from  our  hospitals  by  the  introduction  of 
antiseptic  methods  of  treatment,  although  it  has  been  rendered  much 
less  prevalent  than  formerly. 

Erysipelas  has  been  recognized  from  the  earliest  times,  but  reliable 
data  are  not  obtainable  farther  back  than  the  latter  part  of  the 
eighteenth  century.     The  disease  has  frequently  appeared  as  an  epi- 


ERYSIPELAS.  121 

demic  affection.  Thus,  in  1750  it  was  epidemic  in  France;  in  1777 
and  1800  in  Great  Britain,  and  again  in  the  same  country  in  1821  and 
1832.  In  1842-3  it  prevailed  as  an  epidemic  disease  in  certain  portions 
of  the  United  States.  During-  1843  it  spread  over  Scotland,  Denmark, 
and  Germany.  In  these  epidemics  the  affection  was  marked  by  a 
severity  which  does  not  prevail  to-day.  From  the  accounts  given  of 
the  outbreak  in  America,  it  is  evident  that  it  assumed  in  some  cases  a 
very  malignant  character,  while  in  others  it  resulted  in  extensive  sup- 
purative cellulitis,  the  inflammation  many  times  involving  the  muscles 
and  the  bone.  The  epidemics  of  1842-3  seem  to  have  been  the  last 
supreme  effort  of  the  affection  to  maintain  itself  in  this  particular 
form,  for  there  are  no  records  since  these  dates  of  any  such  extensive 
spread  of  the  disease,  or  of  the  prevalence  of  such  a  severe  type  as  then 
occurred.  Erysipelas,  however,  sometimes  becomes  epidemic  in  cer- 
tain localities  to-day,  where  antiseptic  methods  are  neglected,  and 
occasionally  from  vaccination,  particularly  with  the  humanized  virus 
of  kine-pox. 

Causes. — That  the  disease  is  caused  by  a  specific  microbe  there 
can  no  longer  be  any  question,  and  this  fact  has  been  abundantly 
proven  by  experiments  on  animals  and  man.  The  microbe  of  erysip- 
elas, as  just  stated,  is  a  streptococcus  which  was  discovered  by  Fehl- 
eisen,  and  is  composed  of  serpentine  chains  made  up  of  cocci  of  minute 
•size,  three  to  four  micromillimeters  in  diameter.  The  organism  multi- 
plies by  fission  or  division.  The  pus  streptococcus  and  that  of  erysip- 
elas are  almost  identical,  the  only  discoverable  dift'erence  being  that 
the  cocci  of  erysipelas  are  somewhat  larger,  while  they  are  smaller 
than  the  staphylococci.  Fehleisen  succeeded  in  transmitting  the  dis- 
ease from  man  to  man  by  inoculation  with  the  streptococcus  which  he 
had  isolated.  These  inoculations  were  justified  by  being  used  as  a 
therapeutic  measure  for  the  cure  of  lupus,  rodent  ulcer,  and  inoperable 
sarcomas,  though  the  inoculations  failed  to  cure  the  malignant 
growths.  The  period  of  incubation  of  erysipelas  he  found  to  be  from 
fifteen  to  sixty-one  hours,  and  when  the  culture  with  which  the  disease 
was  produced  was  pure,  it  never  caused  suppuration.  The  ver}'- 
■smallest  dose  did  not  fail  to  produce  the  disease,  differing  in  this 
respect  from  the  staphylococcus,  which  must  be  introduced  in  large 
•doses.  The  investigations  of  Koch,  Rosenbach,  and  others,  in  the 
same  line,  have  abundantly  proved  the  conclusions  of  Fehleisen  as  to 
the  specific  nature  of  the  organism. 

The  very  close  relationship  existing  between  erysipelas  and  puer- 
peral fever,  if  not  their  absolute  identity,  was  suspected  long  before  the 
science  of  bacteriolog}'  made  it  possible  to  identify  the  specific  cause 
•of  the  disease,  and  of  antisepsis  to  prevent  its  spread.  Infection  of  a 
parturient  woman  with  the  erysipelas  streptococci  will  result  in  the 


122  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

establishment  of  puerperal  fever,  while  cultivations  from  the  micro- 
organisms of  puerperal  fever  injected  into  rabbits  will  produce  erysip- 
elas. Dr.  Oliver  Wendell  Holmes  beheved  in  and  taught  this  theory- 
long  before  it  was  possible  to  bring  bacteriologic  proof  of  the  fact. 

The  most  common  location  of  the  streptococci  of  erysipelas  is  in 
the  capillary  lymphatics  of  the  skin,  but  they  are  also  occasionally  seen 
in  the  capillary  blood-vessels  and  smaller  veins.  They  are  found  most 
active  and  in  greatest  number  near  the  margin  of  the  red  border,  or 
"erysipelatous  blush,"  where  the  lymphatics  are  so  crowded  with  them- 
as  to  make  it  difificult  to  discover  the  leucocytes.  They  may  be  found 
outside  of  the  red  border,  or  "lines  of  inflammation,"  in  tissues  as  yet 
unchanged.  The  organisms  do  not  spread  to  other  parts  of  the  body 
through  the  circulation,  though  they  are  occasionally  found  in  the 
vascular  current,  at  some  distance  from  the  seat  of  the  inflammation,, 
but  are  carried  through  the  lymphatics  of  the  skin.     (Warren.) 

The  constitutional  symptoms  which  are  developed  are  in  all  prob- 
ability due  to  the  presence  of  ptomaines  in  the  blood. 

The  disease  may  be  acquired  in  two  ways,  viz:  by  direct  contact 
or  infection,  and  by  contagion  through  the  air,  etc.,  as  in  epidemics. 
Billroth  claims  that  it  is  most  likely  to  occur  in  wounds  which  are 
chiefly  discharging  decomposed  material  mixed  with  blood.  The 
micro-organism  usually  obtains  an  entrance  to  the  system  through  a 
wound  or  an  abrasion.  In  so-called  idiopathic  erysipelas,  where  no 
wound  can  be  discovered,  it  is  more  than  possible  that  the  streptococci 
have  gained  an  entrance  through  an  abrasion  or  wound  which  has 
escaped  notice,  or  it  may  be  from  internal  infection,  the  organism 
having  entered  the  respiratory  or  alimentary  tract,  lodged  in  some 
break  of  continuity  in  the  mucous  membrane,  and  been  absorbed. 

The  clinical  proofs  of  the  contagiousness  of  erysipelas  are  so  abun- 
dant that  doubt  can  no  longer  exist  upon  this  point  in  the  mind  of  the 
observant  surgeon.  The  disease  has  frequently  become  epidemic  in 
certain  localities  as  a  result,  or  rather  as  a  complication,  of  vaccination, 
which  had  for  the  time  being  to  be  abandoned.  The  relationship  of 
erysipelas  and  puerperal  fever  has  already  been  referred  to,  and  that 
both  are  caused  by. the  same  type  of  micro-organism,  if  not  an  identical 
bacterium.  The  contagiousness  of  the  disease  has  become  so  thor- 
oughly recognized  at  the  present  time  that  if  it  should  develop  in  the 
surgical  wards  of  one  of  our  best  hospitals,  the  case  would  be  imme- 
diately isolated,  and  the  patients  removed  from  the  ward  until  it  had 
been  thoroughly  cleaned  and  fumigated,  while  the  nurse  and  the 
surgeon  attending  the  isolated  patient  would  not  be  permitted  to  come 
in  contact  with  those  of  the  surgical  or  obstetrical  wards. 

The  season  of  the  year  and  the  state  of  the  atmosphere  are  thought 
to  have  an  influence  upon  the  development  of  the  specific  organism.. 


ERYSirELAS.  I23 

Epidemics  are  more  likely  to  occur  during  the  winter  and  early  spring- 
months  than  at  other  seasons  of  the  year.  Bad  hygienic  surroundings, 
imperfect  sewerage,  and  the  presence  of  decomposing  substances  favor 
the  growth  and  development  of  the  organism,  and  may  therefore  be 
considered  as  predisposing  causes  of  the  affection. 

It  has  already  been  stated  that  the  most  frequent  point  at  which 
the  virus  enters  the  system  is  through  wounds,  and  from  the  primary 
seat  of  the  infection  it  spreads  rapidly  to  the  surrounding  skin  through 
the  capillary  lymphatics.  The  streptococci  are  chiefly  found  in  the 
lymph  spaces,  but  they  are  occasionally  found  in  the  capillary  blood- 
vessels and  the  small  veins.  The  appearance  of  the  disease  at  distant 
points  from  the  primary  seat  of  the  infection  is  thought  by  some  to  be 
clinical  proof  that  the  virus  may  be  transmitted  through  the  vascular 
circulation.  The  writer  is  of  the  opinion  that  many  times  this  con- 
dition is  the  result  of  auto-infection  through  the  fingers  of  the  patient 
which  have  been  contaminated  with  the  virus;  the  inoculation  taking 
place  by  abrading  the  skin  in  the  act  of  scratching. 

Idiopathic  erysipelas  was  supposed  to  develop  itself  independent 
of  any  traumatic  lesion,  but,  as  already  stated,  it  is  extremely  doubtful 
that  the  virus  could  gain  an  entrance  to  the  system  except  through 
some  lesion  of  the  skin  or  mucous  membrane.  The  lesion  may  be  so 
slight  as  to  have  escaped  notice,  and  yet  offer  an  entrance  sufficient  for 
the  inoculation  of  the  system  with  the  specific  microbe. 

The  general  symptoms  which  accompany  idiopathic  erysipelatous 
inflammation  are  of  such  a  character  as  to  suggest  the  presence  in  the 
circulation  of  a  specific  micro-organism,  or  of  ptomaines  developed  by 
these  organisms. 

Symptoms. — The  symptoms  are  an  initial  chill  or  rigor,  malaise, 
high  temperature,  103°  to  104°  F.,  nausea,  vomiting,  which  is  preceded 
by  heavily-coated  tongue,  and  oppression  in  the  epigastrium;  some- 
times albumin  in  the  urine,  and  the  characteristic  rash  with  a  well- 
defined  margin  upon  the  skin,  rose-red  hue,  with  glazed,  smooth, 
edematous  surface,  which  is  slightly  raised,  stiffness  of  the  parts,  itch- 
ing or  burning  pain,  with  frequently  the  formation  of  vesicles  or  blebs, 
and  enlargement  of  the  lymphatic  glands  in  the  vicinity.  The  most 
marked  characteristic  of  the  disease  is  the  inflammation  of  the  skin, 
and  its  sudden  disappearance  from  one  part  and  its  reappearance  in 
another.  As  soon  as  the  local  inflammation  has  developed,  it  immedi- 
ately shows  signs  of  spreading  in  various  directions.  The  center  of  a 
true  erysipelatous  inflammation  shows  more  or  less  swelling,  with 
diffuse  redness,  but  its  edges  are  marked  by  an  irregular  outline.  The 
red  hue  is  mingled  with  a  yellowish  tinge,  which  becomes  more  evident 
upon  pressure  (Warren);  the  yellow  staining  of  the  skin  being  very 
noticeable  for  the  brief  period  intervening  before  the  return  of  the 


124  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

blood  to  the  capillary  vessels.  The  vesicles,  which  are  minute  in  size, 
often  coalesce  to  form  blebs  and  bullae  of  considerable  size;  these  are 
filled  with  a  clear,  yellowish  serum,  which  may  become  turbid,  and  not 
infrequently  discharge  a  purulent  material.  Yellowish  or  brown  scabs 
are  formed  by  the  drying  up  of  the  smaller  vesicles. 

The  irregular  outline  of  an  advancing  erysipelatous  inflammation 
is  due  to  the  anatomical  relations  of  the  lymph-channels,  through 
which  the  micro-organisms  of  the  disease  extend  to  the  surrounding 
tissue. 

The  duration  of  the  local  inflammation  or  eruption  is  about  four 
days.  At  the  end  of  the  attack  desquamation  takes  place.  The  devel- 
opment of  the  disease  is  greatly  favored  by  filthy  surroundings,  over- 
crowding, and  defective  ventilation.  In  severe  cases  of  the  affection 
the  subsidence  of  the  fever  may  be  followed  by  a  subnormal  tempera- 
ture, sometimes  lasting  for  two  or  three  weeks.  This  condition  is  due, 
probably,  to  the  enfeebled  state  of  the  patient,  as  this  is  the  only 
symptom  of  collapse. 

Diagnosis. — In  well-marked  erysipelatous  inflammation  of  the 
skin,  there  is  no  difficulty  in  making  a  diagnosis.  In  the  early  stages 
of  the  disease,  however,  previous  to  the  development  of  the  local  mani- 
festations, considerable  difficulty  may  be  experienced.  The  nausea, 
vomiting,  and  febrile  symptoms,  with  enlargement  of  the  lymphatic 
glands  in  the  immediate  neighborhood  of  the  wound,  if  not  explainable, 
should  suggest  an  approaching  attack  of  erysipelas.  The  most  reli- 
able diagnostic  signs  are  the  local  rose-red  appearance,  the  peculiar 
doughy  swelHng  of  the  skin,  the  irregular  and  slightly-raised  outline  of 
the  advancing  inflammation,  and  the  yellowish  infiltration.  Bullae 
sometimes  appear  which  are  dark  in  color.  This  is  the  result  of 
hemorrhage,  and  indicates  a  grave  attack.     (Senn.) 

Prognosis. — Uncomplicated  erysipelas  is  not  a  fatal  disease,  ex- 
cept when  it  attacks  very  young  children,  the  aged,  and  those  who 
have  been  debilitated  by  previous  diseased  conditions.  The  affection 
may,  however,  prove  fatal,  but  this  is  usually  the  result  of  some  form  of 
complication,  the  most  common  of  which  are  suppurative  inflamma- 
tion, metastatic  abscesses  from  secondary  infection  with  the  pus-pro- 
ducing micro-organisms,  or  the  extension  of  the  disease  to  the  men- 
inges of  the  brain,  as  sometimes  occurs  when  it  is  located  upon  the  face 
or  head,  or  the  formation  of  secondary  erysipelas  in  vital  organs 
through  the  processes  of  embolism.  The  prognosis,  therefore,  must 
be  based  upon  the  surrounding  conditions,  the  presence  or  absence  of 
complications,  and  their  nature  and  gravity.  One  attack  does  not  give 
immunity,  but  seems  rather  to  predispose  to  other  attacks,  while 
relapses  are  frequent. 

Varieties. — The   other  varieties  of  erysipelas  which  are  usually 


ERYSIPELAS.  I25 

mentioned  are  phlegmonous,  facial,  and  a  rare  variety  attacking  new- 
born children,  erysipelas  neonatorum. 

Phlegmonous  erysipelas  usually  begins  as  the  ordinary  form  in  the 
skin,  but  later  extends  to  the  subcutaneous  tissues.  The  extension  of 
the  disease  to  the  deeper  tissues  is  indicated  by  increased  swelling  of 
the  skin,  which  becomes  tense  and  hard.  Blisters  form,  which  may  be 
filled  with  a  bloody  fluid.  The  swelling  extends  to  the  surrounding 
tissues,  which  may  become  edematous.  The  constitutional  symp- 
toms are  more  marked,  and  the  feyer  assumes  a  typhoid  character. 
Under  these  circumstances,  suppuration,  which  is  an  exceedingly  rare 
complication  in  the  ordinary  form,  is  quite  likely  to  occur.  When 
suppuration  occurs  it  is  not  circumscribed,  but  rather  assumes  the 
character  of  a  purulent  infiltration  of  the  subcutaneous  connective 
tissue.  The  formation  of  pus  is  quite  likely  to  be  announced  by 
rigors.  The  pus,  when  discharged,  is  a  foul,  thin,  watery,  discolored 
fluid,  in  which  are  found  shreds  of  sloughing  connective  tissue.  Large 
areas  may  become  infiltrated,  and  considerable  masses  of  connective 
tissue  destroyed  and  thrown  off.  Numerous  incisions  are  sometimes 
necessary  for  the  proper  drainage  of  the  tissues,  and  for  the  removal  of 
the  sloughing  masses.  Sometimes  the  disease  takes  on  a  malignant 
type,  and  extends  to  the  muscles,  periosteum,  and  bone,  causing  gan- 
grene and  necrosis. 

Phlegvwnous  cellulitis  may  be  distinguished  from  phlegmonous  ery- 
sipelas by  the  absence  of  the  erysipelatous  blush. 

Facial  erysipelas  was  originally  considered  to  be  idiopathic,  but  it 
is  now  believed  to  be  the  result  of  infection,  like  the  other  varieties  of 
the  disease.  In  all  probability,  the  infection  has  occurred  through 
some  slight  wound  or  abrasion  upon  the  face  which  has  been  for- 
gotten or  unnoticed.  The  first  manifestations  of  the  disease  are  a 
slight  redness  or  blush  near  the  root  of  the  nose,  or  the  lachr}^mal 
duct,  spreading  laterally  toward  the  ear.  It  rarely  attacks  the  tip  of 
the  nose,  and  it  is  said  to  have  a  predilection  for  the  right  cheek.  The 
attack  is  generally  ushered  in  by  a  severe  chill.  The  presence  of  en- 
larged lymphatic  glands  is  considered  to  be  characteristic.  The  color 
of  the  skin  is  scarlet  red,  shading  to  a  more  livid  hue  toward  the  ears. 
The  swelling  is  frequently  great,  and  edema  about  the  eyelids  is  com- 
mon, sometimes  completely  closing  them  and  obliterating  all  facial  ex- 
pression. The  spread  of  the  disease  over  the  face  is  by  the  character- 
istic irregular  outline.  The  swelling  of  the  nose  is  often  so  great  as  to 
close  the  nostrils,  making  all  but  mouth-breathing  an  impossibility. 
The  swelling  sometimes  extends  to  the  ears,  causing  impairment  of 
hearing.  The  inflammation  rarely  affects  the  chin,  but  it  may  extend 
downward,  and  involve  the  submaxillary  region.  Its  more  frequent 
course  is  to  spread  toward  the  scalp,  where,  if  the  hair  is  thick,  it  may 


126  SURGERY    OF    THE    FACE,    MOUTH,    AND   JAWS. 

escape  notice.  There  is  often,  however,  a  considerable  swelling  of  the 
neck,  with  enlargement  of  the  glands,  which  are  sensitive  and  painful 
to  pressure.  In  the  severe  form  of  the  disease  the  temperature  will 
run  high,  ranging  from  103°  to  104°  F.,  and  the  fever  will  be  of  the 
continued  type,  with  only  a  slight  evening  increase. 

The  disease  usually  reaches  its  height  in  from  four  to  five  days, 
when  there  is  a  rapid  decrease  in  the  temperature.  Exacerbations  may 
occur,  one  or  more,  before  the  fever  entirely  subsides,  which  are  due  to 
secondary  local  outbreaks  of  the  disease.  Delirium  is  a  frequent  ac- 
companiment of  this  form  of  erysipelas,  and  is  thought  to  be  caused 
either  by  reflex  nerve  action,  disturbance  of  the  vaso-motor  system,  or 
by  septic  intoxication.  The  cerebral  symptoms  are  always  aggravated 
in  those  cases  where  the  disease  involves  the  scalp,  but  no  evidence  of 
pathologic  changes  can  be  discovered  in  the  meninges  of  the  brain,  or 
in  the  brain  itself,  to  account  for  them.  Delirium  in  and  of  itself  is 
not  a  dangerous  symptom,  and  it  usually  subsides  with  the  fever.  Oc- 
casionally suppurative  meningitis  may  occur,  but  it  is  always  caused 
by  direct  extension  of  the  disease  through  the  orbital  fissure  or  the 
cribriform  plate,  when  the  nasal  mucous  membrane  is  involved.  Ab- 
scess, when  it  occurs,  is  usually  located  in  the  orbit.  There  is  a 
marked  tendency  of  this  form  of  the  disease  to  involve  the  tissues  lo- 
cated in  this  cavity.  Gangrene  sometimes  follows  the  edema  and 
extension  of  the  eyelids.  Conjunctivitis,  congestion  of  the  sclerotic, 
and  cloudiness  of  the  cornea  are  not  infrequent  complications,  causing 
more  or  less  disturbance  of  vision.  These  symptoms  disappear  with 
•the  subsidence  of  the  fever  and  the  local  inflammation,  though  blind- 
ness sometimes  results  from  atrophic  degenerative  changes. 

Erysipelas  neonatorum  is  a  fatal  form  of  the  disease,  occurring  in 
newly-born  children,  and  is  very  rarely  seen  outside  the  walls  of 
lying-in  hospitals.  The  affection  bears  a  close  relation  to  puer- 
peral fever.  It  makes  its  appearance  at  about  the  time  of  the  separa- 
tion of  the  umbilical  cord,  its  seat  of  origin  being  in  the  granulating 
surface  of  the  stump  of  the  cord.  The  first  manifestations  of  the 
disease  are  a  slight  rise  in  the  temperature,  and  a  faint  redness  of  the 
skin  about  the  navel  or  the  pubes.  The  inflammatory  symptoms  rap- 
idly increase,  the  redness  becomes  brighter,  and  the  subcutaneous  con- 
nective tissue  is  swollen  and  indurated.  By  the  next  day  the  inflam- 
mation may  have  extended  over  the  abdomen  and  to  the  thighs.  The 
temperature  now  runs  high,  prostration  is  great;  the  child  frets  and 
cries,  and  is  very  restless,  and  finally,  on  the  fifth  or  sixth  day,  falls  into 
collapse  and  dies.  In  the  later  stages  of  the  disease  phlegmonous 
inflammation  or  gangrene  may  occur.  The  arteries  and  veins  some- 
times become  involved  in  the  inflammation,  resulting  in  periarteritis 
and  phlebitis. 


ERYSIPELAS.  I27 

Erysipelas  of  the  Mucous  Membrane. — Erysipelas  very  rarely  has 
its  primary  seat  in  the  mucous  membrane.  The  principal  anatom- 
ical location  of  the  disease  is  the  skin;  but  it  not  infrequently  spreads 
to  contiguous  mucous  membranes.  Erysipelas  of  the  face  frequently 
spreads  to  the  nasal  mucous  membrane,  the  pharynx,  and  glottis.* 
1  he  extension  of  the  infection  to  the  Schneiderian  membrane  may  be 
foretold,  according  to  Raynaud,  by  swelling  of  the  lachrymal  duct, 
through  which  the  disease  passes  to  this  membrane.  Marked  enlarge- 
ment of  the  submaxillary  and  cervical  glands  are  indications  of  the 
spread  of  the  disease  to  the  pharynx.  The  patient  will  complain  of  a 
burning  sensation  in  the  throat,  dryness,  and  dif^culty  in  breathing. 
The  color  of  the  mucous  membrane  will  be  dark  red,  sometimes  show- 
ing in  patches,  at  others  covering  the  entire  throat;  the  swelling,  which 
may  involve  the  tonsils,  is  of  a  marked  character.  Vesicles  form,  and 
later  break,  and  discharge  a  sero-purulent  secretion,  leaving  behind 
little  yellowish-white  patches.  The  duration  of  the  disease  is  from  five 
to  six  days.  It  is  sometimes  complicated  with  gangrenous  inflamma- 
tion, and  abscess  which  simulates  retro-pharyngeal  abscess.  The  dis- 
ease may  pass  downward  to  the  glottis,  causing  edema  of  this  organ. 
It  may  also  extend  to  the  mouth,  involving  the  buccal  mucous  mem- 
brane and  the  tongue,  causing  dark  or  livid  redness,  with  extensive 
swelling,  and  sometimes  the  formation  of  vesicles.  The  tongue  is  the 
part  which  is  the  most  frequently  and  most  extensively  involved.  The 
swelling,  which  is  often  considerable,  is  due  to  the  infiltration  of  the 
mucous  membrane  and  intermuscular  connective  tissue  with  liquid 
and  migratory  cells.  (Ziegler.)  The  disease  often  follows  other  mu- 
cous tracts,  like  the  Eustachian  tubes,  and  passes  to  the  auditory 
canal,  and  thence  to  the  head  and  scalp.  The  beneficial  and  sometimes 
curative  influence  of  erysipelas  upon  diseases  like  lupus,  rodent  ulcer, 
and  inoperable  sarcomas  is  a  remarkable  fact  in  therapetitics. 

Treatment. — The  treatment  of  erysipelas  may  be  divided  into 
local  and  constitutional,  but  from  the  nature  and  course  of  the  dis- 
ease it  must  be  largely  that  of  prevention  and  palliation.  Isolation 
of  the  patient  is  the  first  step  in  the  treatment  of  the  affection,  as 
this  is  the  best  means  of  preventing  its  spread  to  other  persons.  The 
disease  is  one  of  short  duration,  and  when  uncomplicated  is  rarely  a 
•dangerous  condition.  The  value  of  specifics,  either  in  local  or  con- 
stitutional treatment,  is  to  be  seriously  questioned,  for  what  has  seemed 
in  one  case  to  be  successful  has  in  another  proved  a  signal  failure. 

*  A  fatal  case  of  this  character  associated  with  alveolar  abscess  of  the  superior 
■central  incisor  teeth  came  under  the  notice  of  the  writer  as  consultant,  in  which 
the  disease  developed  immediately  after  the  application  of  two  leeches  to  the  lip 
and  left  side  of  the  face.  The  disease  spread  rapidly  over  the  face  from  the  leech- 
bites  ;  thence  extended  to  the  mucous  membrane  of  the  mouth,  pharynx,  and 
glottis  ;  the  patient  dying  from  suffocation. 


128  SURGERY    OF    THE    FACE,    MOUTH,    AND   JAWS. 

From  the  nature  and  cause  of  the  disease,  it  would  seem  probable  that 
the  local  application  of  germicidal  solutions,  like  the  bichlorid  of  mer- 
cury, or  carbolic  acid,  would  be  most  efficacious,  but  this  does  not 
always  prove  to  be  the  case;  while  the  danger  exists,  in  the  use  of 
bichlorid  of  mercury,  of  producing  toxic  conditions  if  the  area  to  be 
treated  is  large,  and  the  solution  of  sufficient  strength  to  destroy  the 
streptococcus;  while  carbolic  acid  of  sufficient  strength  to  accomplish 
the  same  purpose  would  be  likely  to  cause  local  irritation,  and  perhaps 
death  of  the  tissue. 

The  local  symptoms,  particularly  the  burning,  smarting  sensa- 
tions, are  sometimes  greatly  relieved  by  the  application  of  hot  cloths 
wrung  out  of  heated  solutions  of  bichlorid  of  mercury,  i  to  3000;  when 
larger  surfaces  are  to  be  covered,  a  weaker  solution  would  be  advis- 
able. 

Erysipelas  of  the  mouth,  nose,  and  fauces  may  be  treated  with  the 
various  forms  of  antiseptics  already  mentioned,  by  spraying  them  upon 
the  parts.  Used  in  this  manner  they  may  control  the  active  devel- 
opment of  the  specific  micro-organism,  and  assist  in  preventing  com- 
plications arising  from  edema  of  the  mucous  membrane. 

An  ointment  of  carbolic  acid  and  vaselin,  i  to  100,  is  an  excellent 
application  to  the  skin  in  facial  erysipelas.  It  may  be  applied  with  a 
soft  brush,  and  covered  with  thin  rubber  tissue,  oiled  silk,  or  oiled 
paper.  Zinc  ointment  is  sometimes  employed  in  the  same  manner. 
An  ointment  of  ichthyol  in  vaselin  or  lanolin  (flsij  to  5j)  is  considered 
by  some  surgeons  as  almost  a  specific  in  this  disease,  and  relieves  the 
burning  and  smarting  sensation.  Unna  recommends  the  following 
painted  upon  the  surface  with  a  camel's-hair  brush :  Ichthyol  and 
ether  aa  fl5j,  fiex.  collodion  floij. 

In  the  phlegmonous  form  of  the  disease,  free  incisions  for  the 
escape  of  the  discharges  are  always  indicated,  and  should  be  followed 
by  thorough  irrigation.  Sloughing  tissue  may  be  removed,  and  ab- 
scess cavities  should  be  disinfected. 

Isolation  of  the  patient  should  be  maintained  until  desquamation 
has  ceased,  as  there  is  great  danger  from  infection  through  this  source 
during  the  period  of  convalescence.  Warren  thinks  the  tendency  to 
relapse,  which  is  so  frequent  in  this  disease,  may  find  its  explanation  in 
a  reinfection  of  the  wound  from  the  patient's  own  surroundings. 

A  favorite  constitutional  treatment  with  many  is  tincture  fer. 
chlor.,  m  XX  every  two  hours,  supplemented  later  by  quinin  in  tonic 
doses,  gr.  v  to  x  daily.  Milk  diet  and  stimulants  are  indicated;  the 
diet  should  be  as  full  as  the  stomach  will  bear  after  the  first  symptoms 
have  subsided. 

When  the  temperature  runs  high,  antipyretic  drugs  are  demanded. 
Quinin  seems  to  exert  a  beneficial  influence  over  the  local  inflamma- 


ERYSirKLAS.  1 29 

tory  process  and  the  s^eneral  condition  of  the  patient.  When  restless- 
ness is  marked,  a  full  dose  of  Dover's  powder  may  be  given  at  bed- 
time. Symptoms  of  prostration  should  be  early  combated  by  some 
form  of  diffusible  stimulant,  alcoholic  stimulants  having  the  prefer- 
ence. When  collapse  is  threatened,  camphor  administered  every  hour 
in  doses  of  gr.  i^  (Senn),  until  symptoms  of  intoxication  and  reduc- 
tion of  pulse-rate  to  50  or  55  are  produced,  may  prevent  a  fatal  ter- 
mination. 


CHAPTER    XIV. 
TETANUS. 

Definition. — Tetanus  (from  the  Greek  reVavos,  retVav, — to  stretch). 
Tetanus  is  a  disease  causing  spasmodic  and  tonic  contraction  of  mus- 
cles, producing  rigidity  in  the  parts  to  which  they  are  attached.  It  is 
an  infectious  disease,  in  which  a  specific  micro-organism  exerts  a 
pathogenic  action  upon  the  central  nervous  system,  probably  through 
the  production  of  a  chemical  poison  or  ferment. 

The  wound-infective  diseases  in  which  micro-organisms  or  their 
ptomaines  act  upon  the  central  nervous  system,  are  represented  by 
tetanus  and  hydrophobia.  (Senn.)  These  diseases  are  caused  by  spe- 
cific microbes,  and  while  they  produce  no  pathological  changes  of  a 
gross  character  in  the  brain  or  spinal  cord,  minute  tissue-changes,  like 
hyperemia,  take  place,  causing  a  central  irritation,  which  is  made 
manifest  by  tonic  spasm  of  certain  definite  groups  of  muscles. 

The  infectious  nature  of  the  disease  had  long  been  suspected,  but 
it  is  only  very  recently  that  its  true  nature  has  been  demonstrated 
by  the  discovery  of  the  Bacillus  tetani.  The  honor  of  this  discovery 
belongs  jointly  to  Rosenbach  and  Nicolaier.  Nicolaier  found  a 
bacillus  in  earth  which,  when  injected  into  the  tissues  of  animals,  pro- 
duced tetanus.  Rosenbach  found  the  same  bacillus  in  pus  taken  from 
animals  suffering  from  traumatic  tetanus,  and  on  April  lo,  1887,  it  was 
demonstrated  by  Koch  that  the  bacillus  of  Nicolaier  and  that  of  Rosen- 
bach were  one  and  the  same. 

Rosenbach  describes  the  Bacillus  tetani  as  anaerobic  and  in  form  a 
bristle-like  organism,  with  a  spore  at  one  end  of  it,  which  gives  it  the 
appearance  of  a  drum-stick. 

This  micro-organism  is  rapid  in  its  growth,  producing  spores  in 
thirty  hours  in  cultures  which  are  kept  at  a  temperature  equaling  that 
of  the  human  body.  They  possess  great  resistance  to  heat,  as  they 
have  been  found  active  after  having  been  subjected  to  a  moist  heat  of 
80°  C.=i76°  F.  for  one  hour.  When  subjected  to  a  heat  of  100°  C.= 
212°  F.,  for  five  minutes,  it  was  found  that  they  were  destroyed. 

This  bacillus  is  so  common  that  it  has  been  found  in  many  kinds 
of  garden  and  top  soils,  in  street  dust,  sweepings  of  dwellings,  in  old 
masonry,  in  putrefying  fluids  and  manure. 
130 


TETANUS.  131 

Causes. — The  causes  may  be  divided  into  predisposing  and  ex- 
citing. 

The  Predisposing  causes  are  hot  climate,  exposure  to  a  cold  and 
damp  atmosphere,  sudden  changes  of  temperature,  lacerated  and  punc- 
tured wounds,  burns,  frost-bites,  and  all  septic  wounds.  Wounds  of 
the  extremities  are  more  frequently  followed  by  tetanus  than  those  of 
other  parts  of  the  body.  The  negro  race  is  much  more  susceptible  to 
the  disease  than  the  white. 

The  Exciting  cause  is  a  micro-organism  of  marked  anaerobic  type, 
the  Bacillus  tetani,  which  acts  upon  the  central  nervous  system  through 
the  elaboration  of  ptomaines  and  their  poisonous  effects. 

Period  of  Incubation. — The  period  of  incubation  is  exceedingly 
variable,  both  in  man  and  in  animals.  The  symptoms  of  the  disease 
may  develop  in  twenty-four  hours,  or  not  for  several  weeks.  Out  of 
367  cases  reported  in  the  "Surgical  History  of  the  War  of  the  Rebel- 
lion," 287  occurred  during  the  first  two  weeks  after  the  injury.  Yandell 
found  that  of  415  cases,  the  histories  of  which  he  had  gathered,  the 
disease  developed  in  196  cases  during  the  first  two  weeks.  This  varia- 
tion in  the  period  of  incubation  may  depend  upon  the  number  of  the 
bacilli  introduced  at  the  time  of  the  infection;  the  character  of  the 
tissues  at  the  point  of  infection,  which  may  be  favorable  or  unfavorable 
to  their  development ;  or  to  the  vital  resistance  of  the  individual  to  the 
action  of  the  ptomaines  produced  by  the  bacilli. 

Forms  of  the  Disease. — The  disease  develops  in  two  forms, 
namely:  acute  and  chronic,  and  they  are  always  of  traumatic  origin. 
The  old  idea  that  tetanus  in  some  cases  might  be  of  idiopathic 
origin  is  now  no  longer  tenable,  as  the  latest  investigations  have  proved 
conclusively  that  the  disease  is  caused  by  a  specific  micro-organism 
which  gains  access  to  the  circulation,  and  produces  its  toxic  effects 
upon  the  central  nervous  system  through  the  formation  of  ptomaines 
or  a  chemical  ferment.  The  development  of  so-called  idiopathic 
tetanus  can  be  easily  explained  by  the  fact  that  a  slight  wound  or 
abrasion  upon  the  surface  of  the  body  is  sufficient  to  permit  the 
entrance  of  the  micro-organisms;  but  this  may  be  so  trivial  as  to  escape 
the  notice  of  the  individual.  It  is  also  not  improbable  that  infection 
may  occur  through  the  respiratory  mucous  membrane,  or  the  ali- 
mentary tract,  from  the  inspiration  of  dust,  or  the  swallowing  of  food 
contaminated  with  the  organisms. 

Wounds  of  the  hands  and  feet  are  much  more  liable  to  result  in 
tetanus  than  wounds  in  other  locations,  because  the  instruments  or 
substances  inflicting  these  wounds  are  very  liable  to  be  contaminated 
with  infected  earth  or  dust.  They  are  also,  from  neglect,  frequently 
subjected  to  subsequent  infection,  or  infected  foreign  bodies  are 
allowed  to  remain  in  the  wound.     The  disease  is  said  to  have  followed 


132  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

a  simple  fracture.  Under  such  circumstances  the  infection  must  have 
gained  an  entrance  through  some  unnoticed  abrasion  or  wound,  or  by 
internal  infection. 

Tetanus  may  follow  the  extraction  of  teeth,  the  infection  coming" 
from  without, — or  it  may  follow  from  the  infection  of  the  wound  by 
uncleanly  instruments;  it  may  also  follow  the  transplantation  of  teeth, 
where  the  operation  is  not  perfornied  under  aseptic  precautions. 
John  Hunter,  who,  more  than  a  hundred  years  ago,  invented  the 
operation  of  the  transplantation  of  teeth,  finally  discarded  it  for  the 
reason  that  tetanus  was  liable  to  follow  operations  of  this  character. 
The  use  of  antiseptics  has  largely  removed  this  danger,  and  when  per- 
formed under  the  strictest  methods  obtainable  in  the  mouth,  it  is  now 
considered  a  safe  operation.  Hunter's  difficulty  lay  in  two  facts:  first, 
that  he  knew  nothing  of  the  use  of  antiseptics;  and  second,  that  he  did 
not  appreciate  or  did  not  know  the  necessit}^  of  removing  the  pulp  of 
the  tooth,  and  hermetically  sealing  the  pulp-canal  with  some  inde- 
structible filling-material.  Had  he  done  this,  he  would  have  had 
fewer  cases  of  alveolar  abscess  and  less  danger  of  tetanus  following 
the  operation. 

Acute  Tetanus. — This  form  of  the  disease  usually  appears  during 
the  first  and  second  weeks  after  the  injury,  and  reaches  its  height  on 
the  third  or  fourth  day.  The  affection  is  characterized,  in  even  the 
most  acute  cases,  by  its  insidious  approach  and  by  the  absence  of  all 
recognizable  constitutional  symptoms  in  its  early  stages.  The  first 
manifestation  of  the  disease  is  usually  a  sense  of  having  taken  cold, 
followed  by  stiffness  and  soreness  of  the  muscles  of  the  neck  and  jaws. 
The  development  of  the  disease  is  very  rapid  from  this  time,  and  it 
may  terminate  fatally  in  from  four  to  five  days.  In  tropical  climates 
it  develops  much  more  rapidly,  and  cases  have  been  reported  in  which 
death  followed  in  a  few  hours  after  the  first  symptoms  were  discovered. 
When  the  symptoms  are  prolonged  beyond  the  fifth  day,  there  is  hope 
that  the  disease  will  assume  the  chronic  or  milder  form,  and  that 
recovery  will  ultimately  take  place. 

One  of  the  most  common  forms  of  the  disease  is  that  known  as 
trismus,  or  lock-jaw.  Trismus  (from  the  Greek  rptcr/xos,  rpt'^etv, — to 
gnash)  is  a  tonic  spasm  of  the  muscles  of  mastication,  which  firmly 
fixes  the  jaws,  making  it  impossible  for  the  sufferer  to  open  the  mouth. 

A  very  fatal  form  of  tetanus  occasionally  occurs  in  infants  during 
the  first  five  or  six  days  of  life.  It  is  marked  by  frequent  convul- 
sions, occurring  in  paroxysms,  with  rigidity  of  the  muscles  of  the 
body,  and  special  involvement  of  the  muscles  of  the  jaws,  mouth,  and 
throat,  producing  inability  to  swallow.  This  form  of  the  disease  is, 
in  all  probability,  caused  by  infection  at  the  time  of  birth,  or  immedi- 
ately afterward,  through  the  wound  at  the  umbilicus. 


TETANUS.  133 

The  muscles  of  mastication  are  the  first  group  to  be  affected  by 
the  action  of  the  ptomaines  of  the  bacillus  upon  the  central  nervous 
system.  They  are  also,  usually,  the  most  markedly  affected,  and  for 
this  reason  the  term  lock-jaw  has  become  synonymous  for  tetanus. 

Another  condition  known  as  Opisthotonos  (from  the  Greek  omaOtv^ 
behind,  and  t6vo<;^  tone  or  tension)  is  a  tetanic  condition  of  the  mus- 
cles, especially  of  the  back,  which  causes  an  arching  of  the  trunk  back- 
ward, so  that  the  only  point  of  contact  of  the  body  would  be  upon  the 
head  and  heels;  or,  in  other  words,  when  lying  upon  the  back,  the  body 
rests  upon  the  head  and  heels  during  the  spasm.  The  same  condition 
is  characteristic  of  strychnia  poisoning,  hydrophobia,  hysteria,  and 
other  tetanic  affections.  Occasionally  the  trunk  is  arched  forward. 
This  condition  is  termed  Emprosthotonos  (Greek  eix-n-poa-Oev ^  forward, 
and  TWOS,  tension).  At  other  times  the  body  may  be  curved  or  bent 
upon  one  side — curved  laterally — in  a  tetanic  convulsion.  This  is 
termed  Plciirothotonos  (Greek  -n-Xevpodev^  from  the  side,  and  t^lvuv,  to 
bend). 

Symptoms. — The  commencement  of  the  disease  is  marked  by 
chilliness,  slight  stiffness  of  the  muscles  and  jaws,  accompanied  by 
gradually  increasing  pain,  and  the  appearance  of  a  sanious  or  ichorous 
discharge  at  the  wound  or  the  point  of  primary  infection.  The  muscles 
of  deglutition  become  affected,  and  the  individual  experiences  more 
or  less  difficulty  in  swallowing.  The  countenance  presents  a  peculiar 
grinning  expression  (risus  sardonicus).  Later,  all  of  the  voluntary 
muscles,  including  those  of  respiration,  may  become  involved.  The 
affected  muscles  are  rigid  from  tonic  spasm,  but  this  condition  is 
increased  by  frequently  recurring  clonic  spasms. 

In  severe  acute  cases  the  temperature  soon  rises  to  102°  or  104°  F., 
with  a  corresponding  acceleration  of  the  pulse.  The  difference  be- 
tween the  morning  and  evening  temperatures  is  very  slight.  The  men- 
tal faculties  remain  clear  during  the  entire  course  of  the  disease.  The 
salivary  secretions  are  increased,  and  owing  to  the  inability  of  the 
patient  to  swallow  the  fluid,  or  expectorate,  it  escapes  from  the  mouth. 
Respiration  is  affected  in  proportion  to  the  extent  that  the  respiratory 
muscles  are  involved.  In  severe  cases  dyspnea  and  cyanosis  are  early 
manifestations.  The  special  senses  are  not  affected.  The  pain  is 
usually  excruciating,  and  extends  along  the  track  of  the  nerves  supply- 
ing special  groups  of  muscles,  and  it  is  increased  by  the  tonic  spasms, 
or  by  external  irritants.  A  draft  of  cold  air,  an  unexpected  noise,  or 
an  effort  to  swallow,  is  in  some  cases  sufficient  to  produce  a  paroxysm. 
On  account  of  the  difficulty  of  taking  sufficient  food,  the  loss  of  sleep, 
and  the  intense  pain,  emaciation  and  loss  of  strength  are  early  mani- 
festations. As  the  condition  of  exhaustion  becomes  more  marked 
there  is  profuse,  clammy  perspiration,  coldness  of  extremities,  and 


134  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

feeble,  rapid  pulse.  Finally  the  intercostal  muscles  are  affected,  and 
the  diaphragm  is  thrown  into  tonic  spasm,  the  respirations  and  pulse 
cease,  and  death  supervenes.  The  temperature  just  before  death  may 
rise  to  io8°,  to  iio°,  or  even  113°  F. 

Diagnosis. — The  diagnostic  signs  of  tetanus  are  the  absence  of 
fever  in  the  early  stages  of  the  disease,  the  tonic  character  of  the  spasm, 
the  early  manifestations  of  spasmodic  contraction  of  the  muscles  of 
mastication  and  of  the  neck,  the  convulsive  character  of  the  attacks, 
and  the  clearness  of  the  intellectual  faculties  to  the  last. 

The  differential  diagnosis  would  take  into  consideration  the  stiff- 
ness of  the  jaws  arising  from  inflammatory  conditions  of  the  mouth, 
abscesses  associated  with  devitalized  teeth,  impacted  third  molars, 
suppurative  inflammation  of  the  cervical  gland,  inflammation  of  the 
parotid  gland,  rheumatic  conditions  of  the  temporo-maxillary  articu- 
lations, and  reflex  muscular  contractions  due  to  peripheral  irritation  of 
the  nervous  system.  Many  of  the  symptoms  of  strychnia  poisoning 
and  of  hydrophobia  simulate  those  of  tetanus,  and  might  mislead  one 
who  was  not  thoroughly  familiar  with  all  the  symptoms  of  each  of  these 
affections. 

Chronic  Tetanus. — This  form  of  disease  usually  appears  at  a 
later  date  than  the  acute  form,  generally  two  to  three  weeks  after  the 
injury,  and  although  the  symptoms  may  be  very  severe  and  the  devel- 
opment of  the  disease  rapid,  there  will  be  periods  when  the  patient  will 
be  free  from  the  spasmodic  muscular  contractions,  sometimes  for  an 
entire  day.  During  these  periods  the  patient  can  take  nourishment, 
and  his  strength  is  correspondingly  sustained.  The  intervals  between 
the  convulsive  seizures  gradually  become  longer,  and  the  paroxysms 
less  and  less  severe.  After  convalescence  sets  in,  relapses  may  occur 
and  thus  prolong  the  date  of  recovery. 

Prognosis. — The  prognosis  depends  largely  upon  the  character  of 
the  disease.  The  more  acute  and  intense  the  symptoms,  the  greater  is 
the  danger  of  a  fatal  termination.  Tetanus  following  wounds  received 
in  battle  is  much  more  fatal  than  that  following  other  wounds.  Out  of 
505  cases  recorded  during  the  Civil  War,  451  died,  or  89.3  per  cent. 
In  those  cases  which  are  prolonged  beyond  two  weeks,  the  chances  for 
recovery  are  good.  The  general  mortality  of  the  disease  is  about 
seventy-five  in  every  one  hundred.  The  chronic  cases,  as  a  rule, 
recover  after  an  illness  ranging  from  six  to  ten  weeks. 

Treatment. — The  aseptic  treatment  of  all  wounds,  no  matter 
how  small  and  insignificant  they  may  appear,  is  imperative  as  a  pro- 
phylaxis. 

Tetanus  follows  more  frequently  upon  injuries  of  an  insignificant 
nature  than  extensive  wounds,  or  amputations,  for  the  reason  that  the 
minute  lesions  are  overlooked,  or  considered  of  little  or  no  importance; 


TETANUS.  135 

while,  on  the  contrary,  these  lesions  should  receive  the  greatest  care, 
and  be  treated  in  accordance  with  the  strictest  methods  of  antisepsis. 

Old  wounds  should  be  opened,  and  diligent  search  made  for  for- 
eign substances ;  and  recent  traumatisms  should  be  carefully  examined^ 
and  treated  in  the  most  thorough  antiseptic  manner. 

In  severe  cases  palliation  is  the  only  treatment  that  can  be  insti- 
tuted, as  the  immediate  symptoms  are  always  urgent.  The  excruciat- 
ing pain  and  spasm  of  the  muscles  can  generally  be  relieved  only  by  the 
inhalation  of  chloroform.  Its  administration  should  be  conducted  by 
a  competent  person,  and  carried  only  to  the  point  of  muscular  relaxa- 
tion. Morphia,  one-quarter  to  one-half  grain,  combined  with  one  two- 
hundredth  grain  of  atropia,  is  sometimes  of  benefit;  it  should  be  given 
hypodermically. 

In  milder  cases  chloral  hydrate  and  potassic  bromid,  fifteen  to 
twenty  grains,  may  be  given  by  the  stomach  with  good  effect. 

It  is  imperative  that  all  patients  suffering  from  tetanus  should  be 
kept  in  a  quiet  and  dark  room,  and  free  from  all  forms  of  excitement, 
as  absolute  quiet  of  mind  and  body  is  an  important  element  in  the 
treatment. 

In  severe  cases  in  which  swallowing  is  impossible,  food  in  a  liquid 
form  can  be  introduced  into  the  stomach  by  means  of  a  small  elastic 
tube  passed  through  one  of  the  nostrils  into  the  oesophagus;  the  food 
should  be  given  at  regular  intervals.  Surgical  treatment,  by  means  of 
nerve-section  and  nerve-stretching,  gives  no  better  results  than 
internal  medication. 

Startling  reports  have  appeared  in  the  home  and  foreign  medical 
journals  in  reference  to  the  blood-serum  and  antitoxic  treatment  in 
tetanus  and  diphtheria. 

The  mortality  of  tetanus,  according  to  the  recent  statistics  of 
Richter  and  Forgues-Reclus,  is  about  88  per  cent., — this  is  about  13 
per  cent,  higher  than  the  generally  accepted  mortality, — but  it  is 
claimed  that  by  the  new  treatment  this  frightful  mortality  has  been 
reduced  to  20  per  cent.,  with  the  prospect  of  a  still  further  reduction. 

Prof.  Ehrlich,  of  Berlin,  has  recently  demonstrated  that  the  pro- 
tective or  antitoxic  material  is  derived  from  the  normal  substance  of 
the  medulla  dorsalis,  the  antitoxin  being  really  a  constituent  of  the 
medullary  cells  which  has  undergone  solution.  Dr.  Wassermann,  of 
the  Berlin  Institute  for  Contagious  Diseases,  and  Dr.  Takaki,  of  Tokyo, 
have  mixed  the  virus  of  tetanus  with  the  medullary  matter  of  the  spine 
and  of  the  brain  of  healthy  animals  and  inoculated  with  this  mixture 
white  mice.  The  experiments  proved  that  the  dorsal  medulla  and  in  a 
greater  degree  the  brain  of  almost  any  animal,  as  for  instance  the 
guinea-pig,  rabbit,  pigeon,  horse,  and  even  man,  possesses  antitoxic 


156 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


properties  of  the  hig-hest  order,  and  will  protect  the  organism  against 
the  virus  if  the  injection  has  been  made  twenty-four  hours  before. 

In  diphtheria  it  is  more  difficult  to  arrive  at  a  fair  estimate  of  the 
value  of  the  treatment,  on  account  of  the  great  variance  in  the  viru- 
lence of  the  various  epidemics  of  the  disease.  Kossel  reported  233 
cases  treated  by  this  method,  with  179  recoveries,  which  is  equal  to  "]"] 
per  cent.  This  number  included  72  cases  upon  whom  tracheotomy 
had  been  performed,  41  of  whom  recovered,  making  a  percentage  of  57 
as  against  25  in  former  years. 

Diphtheria,  like  tetanus,  is  dependent  upon  the  action  of  a  specific 
micro-organism  which  has  gained  access  to  the  body  through  infec- 
tion or  inoculation,  and  the  production  and  absorption  by  the  system 
of  a  toxic  substance  elaborated  by  the  micro-organisms.     But  there  is 


Fig.  zT- 


I 

Diphtheria  or  Klebs-Lceffler  Bacillus.    X  1200. 


Pseudo-Diphtheria.    X  I2CX3. 


a  possibility  that  pseudo-diphtheria  may  be  mistaken  for  the  more 
serious  form  of  the  malady,  and  thus  render  the  statistics  of  little  value. 
Figs.  36  and  37  represent  the  difference  in  the  size  and  grouping 
between  the  Klebs-Loeffler  bacillus  (true  diphtheria)  and  the  bacillus 
of  pseudo-diphtheria.  A  positive  diagnosis  cannot  be  made  except 
by  a  bacteriologic  examination. 

The  principle  upon  which  the  new  treatment  is  founded  dates  back 
to  the  discovery  of  Jenner,  that  vaccination  with  kine-pox  would 
render  the  human  subject  immune  to  the  virus  of  smallpox.  Jenner, 
however,  had  little  or  no  conception  of  the  great  scientific  principle 
which  he  discovered;  it  remained  for  Pasteur,  Chauveau,  Behring,  and 
others  to  discover  why  and  how  inoculation  with  the  vaccine  virus — 
the  introduction,  in  specified  quantities,  of  the  products  of  certain  spe- 
cific micro-organisms  into  the  system  of  healthy  individuals — would 
protect  them  from  the  disease  caused  by  the  particular  microbe;  and 
in  those  already  suffering  from  the  disease  in  its  earlier  stages,  would 
shorten  the  duration  of  the  attack  and  greatly  reduce  its  virulence. 


TETANUS.  137 

If  confidence  can  be  placed  in  these  reports,  it  would  seem  that 
the  science  of  medicine  has  already  passed  the  threshold  of  the  greatest 
revolution  in  practice  that  the  world  has  ever  seen,  for  the  possibilities 
of  this  line  of  treatment  seem  to  be  almost  limitless. 

With  the  marvelous  achievements  of  vaccination  before  us, — 
the  mortality  from  smallpox  in  England,  before  the  introduction  of 
vaccination,  was  21.2  per  cent.,  while  now  under  the  law  which  requires 
that  every  child  born  in  England  shall  be  vaccinated  before  it  is  three 
months  old,  the  mortality  has  been  reduced  to  0.67  per  cent., — what 
may  we  not  hope  for  in  the  future  in  relation  to  the  terrible  scourges  of 
diphtheria,  phthisis,  cholera,  plague,  etc.,  which  annually  destroy  so 
many  thousands  of  lives  ? 


CHAPTER  XV. 

SHOCK  AND  COLLAPSE. 

Shock. 

Definition. — Shock  (comes  from  the  Saxon,  meaning  to  shake — to 
shake  with  violence). 

"Shock  is  a  lowering  of  the  vital  powers,  the  depression  or  grave 
effects  produced  by  severe  injuries,  operations,  or  profound  mental 
impressions," 

Shock  is  "a  relaxation  or  abolition  of  the  sustaining  and  con- 
trolling influences  which  the  nervous  system  exercises  over  the  vital 
organic  functions  of  the  body,  and  is  the  result  of  a  profound  impres- 
sion made  upon  the  cerebro-spinal  axis,  either  directly,  through  the 
agency  of  an  afferent  nerve,  or-  through  the  circulatory  medium.  It  is 
a  vaso-motor  paralysis,  affecting  also  the  heart,  and  chiefly  the  abdom- 
inal vessels.  It  may  also  be  described  as  a  "sudden  or  instantaneous 
depression  of  organic,  nervous,  or  vital  power,  often  with  more  or  less 
perturbation  of  body  and  mind,  passing  either  into  reaction  or  into  fatal 
sinking, — collapse, — and  occasioned  by  the  nature,  severity,  or  extent 
of  an  injury,  or  by  overwhelming  moral  calamity. 

"A  condition  of  sudden  depression  of  the  whole  functions  of  the 
body,  due  to  powerful  impressions  upon  the  system  by  physical  injury 
or  mental  emotion.  Its  more  obvious  manifestations  are  signs  of  low- 
ered activity  of  the  cardiac,  respiratory,  and  sensorial  functions,  and 
reduction  of  surface  temperature."     (Sir  William  MacCormac.) 

Collapse, 

Collapse  (comes'  from  the  I.atin  collapsus,  fallen  together, — to  fall 
in  ruins; — "Medically,  a  general  prostration  or  failure  of  the  vital 
powers, — a  complete  prostration  of  strength,  either  at  the  commence- 
ment or  in  the  progress  of  a  disease"). 

"Collapse  is  a  state  of  nervous  prostration.  When  it  is  extreme, 
the  vital  functions  are  in  a  condition  of  partial,  and  sometimes  nearly 
complete,  abeyance.  It  may  terminate  in  death,  or  be  followed  by 
general  reaction  and  complete  recovery. 

"Collapse  and  shock  have  usually  been  classed  together,  but  it  is 
not  accurate  to  do  so.  It  is  true  that  the  ganglionic  centers  of  the 
138 


SHOCK    AND   COLLAPSE.  139 

medulla  oblongata  are  more  or  less  profoundly  involved  in  both,  and 
that  both  possess  many  symptoms  in  common,  dependent  upon  the 
derangement  of  function  of  one  or  more  of  these  centers.  Some  con- 
fusion is  attributable  to  the  fact  that  shock  is  a  term  applied  not  only  to 
a  state  or  morbid  condition,  but  the  cause  which  most  frequently  pro- 
duces that  condition, — a  violent  impression  or  shock  to  the  nervous 
centers.  Collapse  arises  from  many  different  causes,  shock  being  one, 
of  which  collapse  may  be  regarded  as  a  final  and  extreme  degree,  and 
into  which  it  often  imperceptibly  passes.  Collapse,  on  the  other  hand, 
may  occur  under  conditions  where  there  has  been  no  antecedent  state 
of  shock.  Collapse  presupposes  previous  nervous  exhaustion,  while 
shock  may  instantly  appear  in  a  healthy  individual."  (Sir  William 
MacCormac.) 

Shock,  therefore,  may  appear  instantaneously  in  healthy  individ- 
uals, from  fright,  extreme  mental  emotion,  traumatic  injury,  or  surgical 
operation,  the  depression  of  vital  force  corresponding  to  the  severity 
of  the  impression  made  upon  the  nerve-centers,  the  tendency  being 
generally  toward  reaction,  which  may  take  place  in  a  few  minutes  or 
be  delayed  for  several  hours,  while  in  severe  cases  it  may  terminate 
fatally. 

Collapse,  on  the  other  hand,  generally  manifests  itself  in  persons 
who  have  undergone  previous  prolonged  nervous  strain  which  has 
caused  exhaustion.  The  system  is  therefore  at  a  disadvantage,  if  called 
upon  to  sustain  the  debilitating  effects  of  disease,  or  any  of  the  emo- 
tional, traumatic,  or  surgical  conditions  just  mentioned.  The  depres- 
sion of  vital  force  is  more  prolonged  and  extreme,  depending  upon  the 
strength  of  the  individual  and  the  character  and  degree  of  the  exciting 
cause.  Reaction  sets  in  less  quickly,  and  complete  recovery  may  re- 
quire weeks  or  months  for  its  accomplishment. 

Collapse,  in  its  most  extreme  form,  following  cholera,  yellow 
fever,  or  shock  from  severe  accident  or  surgical  injury,  generally 
proves  fatal.  Shock  with  profuse  hemorrhage  often  causes  fatal  col- 
lapse. 

In  the  normal  condition  of  the  system  there  is  a  very  great  differ- 
ence in  the  nervous  excitability  and  physical  endurance  of  individuals, 
while  in  the  same  person,  under  abnormal  conditions,  the  individual 
peculiarities  are  accentuated.  All  are  less  able  to  endure  the  shock  of 
accident  or  surgical  injury,  the  extremes  of  joy  or  grief,  if  the  physical 
or  mental  conditions  are  below  the  normal.  Women,  taken  as  a  class, 
are  less  susceptible  to  shock  than  men;  temperament  also  exerts  a 
modifying  influence  in  shock.  The  phlegmatic  and  lymphatic  tem- 
peraments do  not  possess  the  same  susceptibility  to  shock  as  is  found  in 
the  sanguine  and  nervous.  Age  is  also  a  strong  modifying  factor  in 
shock.       Children  bear  injuries  well,  and  quickly  rally  from  shock 


I40  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

when  the  injury  has  not  been  accompanied  with  much  loss  of  blood. 
In  the  aged,  on  account  of  the  presence  of  org-anic  diseases,  or  debility, 
shock  is  often  of  a  severe  and  prolonged  character. 

Pathology. — Very  little  is  known  of  the  pathology  of  shock,  as  it 
is  one  of  those  conditions  which  cannot  be  demonstrated  by  the  ordi- 
nary methods  of  research.  In  persons  who  have  died  from  shock,  it  is 
impossible  to  discover  any  pathologic  changes  to  have  taken  place  in 
the  tissues.  The  principal  phenomena  of  shock  are  those  which  occur 
or  manifest  themselves  through  the  agency  of  the  nervous  system. 
Goltz  discovered  a  marked  distention  of  the  intra-abdominal  veins  in 
certain  cases  of  shock.  Experimental  physiology  has  demonstrated 
beyond  a  doubt  that  in  shock  there  is  a  reflex  paralysis  of  the  heart 
and  abdominal  vessels,  brought  about  through  the  medium  of  the 
vaso-motor  system.  All  the  symptoms  of  shock  are  of  such  a  nature 
as  would  indicate  a  more  or  less  severe  paralysis  of  the  heart  and 
vessels,  with  the  accompanying  impression  upon  the  nervous  system 
and  the  brain. 

Symptoms. — The  symptoms  of  shock  comprehend  those  of  de- 
pression of  the  vital  forces,  which  may  be  slight  or  grave,  according 
to  the  extent  of  the  injury  or  the  force  of  the  mental  impression,  and 
the  nervous  susceptibility  of  the  individual.  The  most  striking  symp- 
toms of  shock  are  the  contracted,  pinched  expression  of  the  features; 
the  sickly-white  hue  of  the  skin ;  the  thin,  pale  lips ;  the  sunken  appear- 
ance of  the  eyes;  the  cold,  clammy  feeling  of  the  surface  of  the  body; 
the  feeble,  rapid  pulse;  the  shallow  and  irregular  respiration;  the  sub- 
normal temperature;  the  general  relaxation  of  the  muscular  system, 
and  loss  of  control  of  the  sphincters,  causing  involuntary  evacuations, 
while  consciousness  and  the  special  senses  are  often  considerably 
blunted;  the  sensation  of  pain  is  more  or  less  diminished,  and  nausea 
and  vomiting  frequently  occur.  Reaction  may  take  place  in  a  few 
hours,  or  not  for  twenty-four  hours,  or  the  condition  of  shock  may 
terminate  in  collapse  and  the  patient  die  from  syncope  or  asthenia. 

Normal  reaction  is  characterized  by  an  increase  in  the  strength  of 
the  heart-action,  with  diminution  in  the  rapidity  of  its  pulsation,  a  rise 
in  the  body  temperature,  return  of  the  natural  color  of  the  skin,  and  a 
re-establishment  of  full,  deep  inspirations.  Another  form  of  reaction — 
abnormal — sometimes  takes  place,  in  which  acute  fever  is  developed, 
with  flushed  face,  bloodshot  eyes,  high  temperature,  extreme  restless- 
ness, rapid,  throbbing  pulse,  and  delirium.  The  pulse,  however,  does 
not  possess  the  characteristics  of  high  fever,  as  it  is  soft  and  com- 
pressible. The  tongue  is  dry,  and  the  general  condition  one  of  great 
weakness  and  prostration.  This  form  of  shock  is  very  liable  to  lapse 
into  profound  shock  and  fatal  collapse. 

Prognosis. — The    prognosis    of    shock    will    depend    very    largely 


SHOCK    AND    COLLAPSE.  I4I 

upon  the  severity  of  the  mjury,  or  extent  of  the  mental  impression, 
and  the  reactive  powers  of  the  individual;  but  the  outcome  is  always 
uncertain  and  doubtful.  Shock  may  prove  fatal  in  the  brief  space  of  a 
few  seconds,  or  the  individual  may  not  succumb  for  twenty-four  to 
forty-eight  hours.  The  prognosis  of  shock  is  considered  unfavorable 
if  reaction  (^oes  not  set  in  within  eighteen  to  twenty-four  hours,  or  if 
the  temperature  falls  below  96°  F.  Such  a  condition  contra-indicates 
any  surgical  operation.  Another  particularly  unfavorable  symptom  is 
the  loss  of  the  power  of  swallowing.  Loss  of  sensation  in  the  con- 
junctiva, persistent  vomiting,  and  relaxation  of  the  sphincter  muscles 
are  also  considered  as  fatal  symptoms. 

Treatment. — In  those  cases  of  shock  which  may  be  classed  as 
mild,  very  little  in  the  line  of  treatment  is  required  beyond  that  of 
keeping  the  patient  warm  and  quiet,  and  allowing  nature  to  restore  the 
equilibrium  of  the  circulation  and  the  forces  of  the  nervous  system. 
Occasionally  a  little  stimulation  may  be  advantageously  employed,  but 
generally  the  administration  of  drugs  under  these  circumstances  is 
more  harmful  than  beneficial.  In  the  severer  cases  of  shock,  the  meas- 
ures employed  should  be  of  such  a  nature  as  will  tend  to  stimulate  the 
vital  forces,  which  at  such  a  time  are  at  an  exceedingly  low  ebb.  The 
principal  indications  or  requirements  in  the  treatment  of  shock  are  the 
preservation  and  supply  of  heat  to  the  body;  to  stimulate  the  feeble 
action  of  the  heart,  to  allay  restlessness,  to  control  the  hemorrhage 
and  other  complications  as  they  may  arise.  If  shock  supervenes  dur- 
ing a  surgical  operation,  the  operation  should  be  terminated  as  speedily 
as  possible,  or  it  may  even  be  better  to  suspend  it  altogether.  Better 
this  than  that  the  life  of  the  patient  should  be  sacrificed  to  a  prolonga- 
tion of  the  operation. 

Persons  suffering  from  shock  should  be  placed  in  a  comfortable 
position  upon  the  back ;  the  foot  of  the  bed  elevated  so  as  to  bring  the 
head  lowest,  that  the  weak  heart  may  be  called  upon  to  expend  the 
least  possible  amount  of  energy  in  forcing  the  blood  to  the  exhausted 
vital  nerve-centers.  Rest  and  quiet  are  of  the  utmost  importance,  and, 
after  the  patient  has  been  placed  in  bed,  he  should  remain  there  with- 
out disturbance  until  reaction  has  set  in.  Next  of  importance  to  undis- 
turbed rest  is  the  application  of  heat  to  the  body.  This  may  be  accom- 
plished by  placing  about  the  extremities  and  side  of  the  body  of  the 
patient  bottles  filled  with  hot  water;  hot  bricks  or  other  suitable  means 
can  be  used  for  the  same  purpose,  care  being  taken  to  protect  the 
patient  from  being  burned  with  the  hot  appliances.  The  artificial  heat 
should  be  confined  by  covering  the  patient  with  blankets,  and  over 
these  a  rubber  sheet. 

In  severe  cases  of  shock  resulting  from  accident, '  the  patient 
should  be  moved  as  little  as  possible,  while  the  clothing  should  not  be 


142  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

removed  unless  it  is  wet  or  some  other  cause  imperatively  demands  it. 
Unnecessary  disturbance  under  such  circumstances,  even  to  clean  up 
the  patient,  is  productive  of  more  harm  than  good,  while  the  examina- 
tion of  the  medical  attendant  should  be  as  gentle  and  quiet  as  possible, 
for  the  same  reason.  The  necessary  manipulations  for  the  control  of 
the  hemorrhage,  and  the  care  of  the  wounds,  should  be  done  in  the 
most  expeditious  manner  possible  consistent  with  the  best  interests  of 
the  patient  at  the  time,  and  for  his  future  well-being. 

In  shock  and  collapse  resulting  from  severe  hemorrhage,  trans- 
fusion of  blood  was  at  one  time  extensively  practiced.  This  treatment, 
of  late  years,  has  been  practically  abandoned,  on  account  of  the  diffi- 
culties and  dangers  which  surrounded  it.  Intravenous  infusion  or 
hijection  of  warm  salt  solutions  is  now  practiced  to  a  considerable 
extent,  and  with  quite  as  good,  if  not  better,  results.  The  chief  ad- 
vantages of  a  saline  solution  are  that  it  can  always  be  procured  in  a 
few  minutes,  and  that  it  can  be  introduced  with  the  ordinary  fountain, 
or  other  good  syringe  which  will  carry  a  continuous  stream,  and  permit 
of  being  charged  while  in  position. 

Mikulicz  suggested  the  following  formula: 

Sodii  chlorid.,  3jss; 
Sodii  bicarb.,  gr.  xv; 
Aq.  dest.,  Oij.— M. 

The  temperature  of  the  solution  should  be  ioo°  F. 

It  may  be  introduced  into  the  median  cephalic  vein,  or  into  the 
subcutaneous  connective  tissue  of  the  abdominal  wall.  The  injection 
should  be  made  slowly,  and  care  taken  that  air  is  not  introduced  with  it. 
The  quantity  which  may  be  safely  injected  will  vary  from  one  to  four 
pints.  The  pulse  and  respirations  are  to  be  carefully  noted  during  the 
injection. 

Patients  suffering  from  shock  induced  by  hemorrhage  are  inclined 
to  drink  large  quantities  of  water.  This  is  nature's  method  of  supplying 
the  deficiency  of  fluid  at  the  vital  centers.  There  can  be  no  objection, 
therefore,  to  its  use,  provided  the  stomach  is  in  a  condition  to  retain  it. 
In  irritable  conditions  of  the  stomach,  where  the  water  is  not  borne 
well,  recourse  may  be  had  to  rectal  injections  of  weak  salt  solutions  at 
a  temperature  of  ioo°  F.  A  quart  or  more  may  be  injected  at  a  time, 
and  repeated  in  half  an  hour,  for  absorption  goes  on  with  amazing 
rapidity  in  the  lower  bowel  of  persons  whose  systems  have  been  de- 
pleted by  the  loss  of  large  quantities  of  blood. 

Dififusible  stimulants  are  of  great  value  in  cases  of  shock,  and  may 
be  administered  as  the  indications  suggest,  either  by  the  stomach  or 
hypodermically.  Whiskey  or  brandy  are  the  best  for  this  purpose, 
and  may  be  injected  in  doses  from  fl  3ss  to  fl  3J,  and  repeated  every 
ten  or  fifteen  minutes  until  a  decided  stimulant  effect  is  produced  upon 


SHOCK    AND    COLLAPSE.  I43 

the  heart's  action,  as  manifested  in  improvement  of  the  pulse.  The 
heart's  action  may  be  further  strengthened  and  the  nausea  reHeved  by 
the  administration  of  black  coffee  in  small  and  frequent  doses,  either 
alone  or  in  combination  with  brandy.  The  aromatic  spirit  of  ammonia 
is  also  a  valuable  diffusive  stimulant,  and  is  generally  well  borne  by 
the  stomach,  dose  gtt.  xxv  to  fl  oj,  in  water. 

Opium  in  small  doses,  administered  by  hypodermic  injections  or 
by  rectal  injection,  is  often  recommended  for  its  stimulating  action, 
and  for  the  quieting  influence  which  it  exerts  at  a  time  when  repose  is 
of  so  much  importance.  Digitalis,  alone  or  combined  with  atropin,  is 
often  administered  in  those  cases  in  which  collapse  is  threatened. 
Digitalis  is  a  powerful  cardiac  restorative,  but  it  is  not  well  borne  by 
the  stomach,  hence  it  is  best  administered  by  hypodermic  injection. 
The  dose  of  the  tincture  of  digitalis  is  gtt.  xv.  This  may  be  repeated 
every  fifteen  or  twenty  minutes  until  the  pulse  shows  decided  improve- 
ment, but  not  more  than  three  or  four  consecutive  doses  should  be 
administered.  The  first  dose  only  should  be  combined  with  atropin; 
one  one-hundredth  of  a  grain  is  the  usual  dose. 

Nitro-glycerin  in  doses  of  one  two-hundredths  of  a  grain  is  often 
of  service  in  those  cases  where  digitalis  fails  to  stimulate  the  flagging 
action  of  the  heart. 

Strychnia  in  doses  of  one-fiftieth  to  one-thirtieth  of  a  grain  is 
highly  recommended  by  some  authorities  in  such  emergencies. 

As  soon  as  reaction  begins  the  stimulant  should  be  gradually  with- 
drawn, but  the  pulse  should  be  carefully  watched  in  the  meantime, 
and,  if  signs  of  relapse  appear,  the  stimulant  should  be  immediately  re- 
newed, and,  as  soon  as  indications  warrant,  again  gradually  withdrawn. 
The  means  which  have  been  employed  to  restore  the  normal  tempera- 
ture of  the  body  may  be  removed  as  soon  as  the  patient  complains  of 
discomfort  from  their  use. 

Shock  from  Dental  Operations. — Prolonged  and  painful  dental 
operations  commonly  produce  considerable  depression  of  the  vital 
powers.  In  individuals  already  in  a  more  or  less  exhausted  condition 
from  disease,  overwork  of  mind  or  body,  or  emotional  causes,  and  oc- 
casionally in  chlorotic  girls,  pregnant  women,  or  those  suffering  from 
uterine  or  ovarian  diseases,  and  in  frail,  delicate  children,  they  may  pro- 
duce alarming  symptoms  of  shock.  It  is  therefore,  in  view  of  the  fore- 
going facts,  as  much  the  duty  of  the  dental  surgeon  to  look  carefully 
into  the  general  condition  of  health  of  those  who  present  themselves 
for  dental  operations,  as  it  is  for  the  general  surgeon  to  do  so  before 
commencing  any  surgical  procedure.  Only  in  extreme  cases  where 
immediate  operation  seems  necessary,  as  the  only  chance  of  pre- 
serving life,  will  the  intelligent  surgeon  permit  himself  to  operate  upon 
individuals  whose  physical  condition,  as  in  shock  and  collapse  result- 


144  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

ing  from  hemorrhage,  strangulated  hernia,  perforation  of  the  bowel 
from  traumatism,  certain  brain  injuries,  etc.,  or  where  the  general 
health  is  greatly  impaired,  without  first  making  the  attempt  to  stimu- 
late the  flagging  energies  of  the  heart  or  to  recuperate  the  depressed 
vitality,  and  place  the  patient  in  the  best  possible  condition  for  the 
operation. 

Failure  to  properly  appreciate  the  necessity  of  such  treatment 
tends  to  disappointment  or  disaster,  of  greater  or  less  moment,  either 
in  the  success  of  the  operation,  the  after-effects  upon  the  system,  or  the 
life  of  the  patient. 

There  are  but  few  strictly  dental  diseases  which,  per  se,  are  dan- 
gerous to  life  in  the  otherwise  healthy  individual,  and  few  operations 
upon  the  teeth,  or  immediately  associated  tissues,  which  can  in  any 
sense  be  considered  dangerous  to  the  same  class  of  persons ;  yet  the 
presence  of  an  alveolar  abscess,  or  the  extraction  of  a  tooth,  occa- 
sionally proves  fatal,  either  from  septic  infection,  a  peculiarity  in 
diathesis, — hemorrhagic, — or  some  pre-existent  morbid  tendency 
which  predisposes  to  a  fatal  termination. 

On  the  other  hand,  painful  or  prolonged  operations  upon  the 
teeth,  like  the  preparation  of  a  series  of  exceedingly  sensitive  cavities 
of  decay,  or  restoring  the  contour  of  the  teeth  with  gold,  is  very  de- 
pressing and  irritating  to  the  nervous  system,  and  fatal  results  may 
follow  such  operation  in  consequence  of  reflex  impressions  made 
through  the  fifth  nerve  upon  vital  ganglia. 

The  dentist,  unfortunately,  is  usually  obliged  to  perform  these 
operations  without  the  benefit  of  any  of  the  anesthetics.  The  nature 
of  the  operations,  the  necessarily  upright  position  of  the  patient,  the 
considerable  amount  of  time  required  to  complete  them,  and  the  diffi- 
culties encountered  in  the  maintenance  of  anesthesia  preclude  the  use 
of  these  agents;  consequently  shock  and  collapse,  in  various  degrees, 
are  often  the  sequel  of  the  severe  strain  upon  the  nervous  system  to 
which  the  individual  has  been  subjected.  It  is  not  at  all  uncommon 
for  strong,  robust  men  to  develop  various  symptoms  of  shock  after 
sitting  for  two  or  three  hours  under  such  manipulations. 

Children  especially  should  not  be  compelled  to  submit  to  the 
fatigue  and  nervous  strain  of  long  and  painful  operations,  particularly 
during  the  period  of  rapid  growth,  puberty,  and  just  preceding  it;  while 
engaged  in  severe  study,  or  just  after  a  prolonged  illness.  At  these 
periods  the  nervous  system  is  generally  taxed  to  its  utmost  limit  of 
endurance.  When  crowded  beyond  this  point,  the  health  gives  way, 
and  often,  when  too  late,  it  is  discovered  that  the  foundation  has  been 
laid  for  a  train  of  nervous  affections,  chorea,  etc.,  which  persist  to  the 
end  of  life. 

The  rapid  movement  of  the  teeth  by  the  various  methods  employed 


SHOCK    AND    COLLAPSE.  I45 

in  orthodontia  is  often  a  serious  and  dangerous  operation,  on  account 
of  the  severe  and  constant  irritating  influences  upon  the  nerve-centers. 
It  would  be  much  better  to  forego  the  attempt  to  improve  the  personal 
appearance  of  the  child  than  to  destroy  the  health. 

Chlorotic  girls  and  women  suffering  from  uterine  and  ovarian 
diseases  in  their  manifold  forms,  or  during  gestation  and  the  functional 
changes  which  establish  the  menopause,  are  usually  in  a  more  or  less 
exalted  state  of  nervous  irritability,  and  the  nerve-centers  seem  to  be 
more  easily  impressed,  while  reflex  disturbances  are  common.  As  a 
consequence,  dental  operations  of  any  kind  are  not  well  borne  by  such 
individuals. 

When  the  operations  are  of  a  prolonged  and  painful  character, 
they  should  not  be  undertaken  unless  they  can  be  performed  with  the 
help  of  anodynes  or  of  anesthetics.  In  most  cases  it  would  be  far 
better  to  adopt  palliative  and  temporary  measures  until  such  time  as 
the  health  is  restored,  rather  than  by  heroic  treatment  to  run  the  risk 
of  nervous  exhaustion  or  more  serious  consequences.  Miscarriage 
and  other  serious  affections  are  not  unheard  of  as  sequels  of  heroic 
dental  operations. 

Shock  from  the  extraction  of  teeth  is  often  severe,  sometimes 
inducing  alarming  symptoms;  syncope  is  the  most  common,  but  this 
is  frequently  followed  by  a  decrease  in  the  surface  temperature,  cold 
perspiration,  feeble  pulse,  muscular  tremor,  nausea,  and  vomiting.  In 
the  more  severe  cases,  the  depression  may  be  so  great  as  to  cause  a 
fatal  termination. 

Cases  of  death  following  the  extraction  of  teeth  under  the  influ- 
ence of  anesthetics,  and  sometimes  erroneously  attributed  to  heart- 
disease,  are  no  doubt  often  the  result  of  shock,  induced  by  the  progress 
of  the  operation  before  the  sensory  nerves  were  completely  paralyzed 
by  the  action  of  the  anesthetics. 

The  fifth  nerve  is  considered  to  be  the  most  sensitive  nerve  of  the 
body,  and  it  is  also  among  the  last  to  yield  to  the  influences  of  anes- 
thetic drugs.  The  necessity,  therefore,  of  complete  anesthesia  in  tooth- 
extraction,  or  in  any  other  operation  in  which  this  nerve  is  involved,  is 
self-evident. 

The  object  of  anesthesia  is  to  annihilate  pain  and  prevent  shock 
from  surgical  injury;  but  if  it  is  not  carried  to  the  point  of  profound 
impression,  or  complete  insensibility,  the  desired  result  is  not  attained. 
The  loss  of  mental  consciousness  is  not  anesthesia,  but  this  condition 
takes  place  some  time  before  the  sensory  function  of  the  fifth  nerve  is 
paralyzed.  There  is  much  less  danger  to  life  from  shock  in  surgical 
operations  under  profound  anesthesia  than  when  it  is  incomplete. 
Partial  anesthesia  invites  shock,  while  profound  anesthesia  prevents  it. 

Cases  are  on  record,  in  considerable  number,  of  persons  who  have 


146  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

died  from  shock  superinduced  by  mental  excitement,  fright,  sudden 
joy,  or  great  grief,  or  the  dread  of  a  surgical  operation,  sometimes  of  a 
trivial  nature.  In  many  of  these  cases  there  was  evidence  of  abnormal 
conditions  of  the  system,  often  associated  with  diseases  of  the  heart. 

Lauder  Brunton  relates  a  remarkable  case  of  sudden  death  from 
shock,  the  result  of  mental  emotion.  Some  medical  students  seized  the 
janitor,  who  had  displeased  them,  and  made  him  believe  they  intended 
to  behead  him.  They  blindfolded  him,  placed  him  upon  a  block, 
then  struck  him  a  sharp  blow  upon  the  back  of  the  neck  with  a  wet 
towel.  On  removing  the  bandage  they  were  horrified  to  find  that  he 
was  dead. 

Several  years  ago,  in  a  city  in  central  Xew  York,  a  lady  past  fifty 
years  of  age  called  upon  a  dentist  for  the  extraction  of  an  aching  tooth. 
She  was  placed  in  a  chair  preparatory  to  the  operation,  when  almost 
immediately  she  expired.  The  post-mortem  examination  revealed 
fatty  degeneration  of  the  heart.  The  coroner's  verdict  was  death  from 
heart-disease,  caused  by  fright.  This  is  an  exceptional  case,  but  it 
illustrates  the  fact  that  shock  is  sometimes  superinduced  by  mental 
excitement,  and  that  it  may,  under  certain  weakened  conditions  of  the 
heart,  terminate  in  instant  death. 

A  lawyer,  aged  fifty  years,  strong  and  robust,  and  of  great  physi- 
cal endurance,  applied  for  dental  treatment.  Five  years  before  he  was 
injured  by  his  horse  falling  upon  him,  breaking  the  right  femur  and 
fracturing  several  ribs.  The  nervous  shock  was  very  great,  and  he 
never  fully  recovered  from  it.  Before  the  accident  he  had  always 
prided  himself  upon  being  able  to  endure  any  amount  of  physical  suf- 
fering incident  to  dental  operations  without  flinching.  After  the  acci- 
dent he  was  never  able  to  endure  a  sitting  of  more  than  fifteen  or 
twenty  minutes  long,  while  during  the  whole  time  cold  perspiration 
would  stand  in  great  drops  upon  his  forehead,  and  he  would  complain 
of  suffering  the  most  intense  agony.  It  was  only  possible  to  insert 
temporary  fillings  from  this  time  until  his  death,  which  occurred  about 
two  years  later.  The  fatigue  and  prostration  following  even  these 
short  sittings  were  very  considerable,  emphasizing  the  fact  that  the 
character  of  the  operations  must  be  tempered  to  the  physical  condition 
of  each  individual. 

The  various  symptoms  and  conditions  of  surgical  shock  and  col- 
lapse occasionally  following  dental  operations  to  the  healthy  and  robust 
individual  may  be  of  trivial  moment,  but  in  those  of  exalted  nervous 
susceptibility,  the  physically  or  mentally  overworked  or  depressed,  and 
those  in  whom  vitality  is  low  from  chronic  ailments,  or  because  just 
recovering  from  acute  disease,  may  result  in  serious  and  sometimes 
fatal  consequences. 

The  prevention  of  such  untoward  results  will  depend  very  largely 


SHOCK    AND    COLLAPSE.  147 

Upon  the  ability  of  the  sui-geon  or  dentist  to  correctly  diagnosticate 
the  physical  conditions  of  individuals  presenting-  themselves  for  treat- 
ment, to  correctly  judge  as  to  the  amount  of  fatigue  and  nervous  strain 
each  can  endure  without  detriment  to  health,  and  the  proper  use  of 
drugs  and  other  means  at  his  command  to  mitigate  the  suffering  from 
such  operations. 

The  following  formulae  may  be  used  with  benefit  in  allaying  ner- 
vous irritability  and  in  preventing  shock  from  dental  operations : 

iR — Croton  chloral  hydrate,  gr.  x; 
Bourbon  whisky,  flS  j. 
Sig. — Twenty  minutes  before  operation. 
For  an  adult. 

^ — Morphia  sulf.,  gr.  yi; 
Bourbon  whisky,  flo  j. 
Sig. — Thirty  minutes  before  operation. 
For  an  adult. 

5 — Potassium  bromid,  gr.  xx  to  xxx; 
Cinnamon  water,  flo  j. 
Sig. — Thirty  minutes  before  operation. 
For  an  adult. 

IJ — Potassium    bromid,    gr.    xv   to    xx; 
Croton  chloral  hydrate,  gr.  x; 
Cinnamon  water,  flo  j. 
Sig. — Thirty  minutes  before  operation. 
For  an  adult. 


CHAPTER    XVI. 
LIGATURES,  SUTURES,  AND  SUTURING. 

Ligatures. 

Definition. — Ligature  (Lat.  ligare,  to  tie).  A  ligature  is  a  cord 
or  thread  of  any  material  that  is  used  for  tying  arteries,  or  ligating 
abnormal  growths,  etc. 

Silk,  catgut,  silkworm-gut,  and  horse-hair  are  the  materials  most 
commonly  used  for  the  purposes  of  ligation. 

The  animal  ligatures  are  made  from  the  sheep's  gut,  the  sinews, 
tendons,  and  the  skins  of  various  animals. 

All  animal  ligatures  are  capable  of  being  absorbed. 

When  a  ligature  is  to  be  applied  to  a  deep-seated  vessel  and  the 
wound  closed  over  the  ligature, — buried, — absorbable  materials  in 
most  cases  should  have  the  preference. 

Catgut  is  most  frequently  used  for  buried  ligatures.  This  mate- 
rial is  made  from  the  middle  coat  of  the  intestines  of  the  sheep  previ- 
ously treated  to  render  it  tough  and  strong,  and  cut  into  threads  of 
various  sizes  to  suit  the  demand. 

The  first  absorbable  ligature  was  made  and  used  by  Dr.  Physick, 
who  utilized  the  untanned  buckskin  for  this  purpose. 

Horse-hair  makes  an  excellent  ligature  when  formed  by  braiding 
several  strands  together,  and  it  becomes  exceedingly  strong  and  pliable 
when  immersed  in  oil  for  a  considerable  period.  It  is  capable  of  slow 
absorption. 

In  selecting  horse-hair  for  ligatures  and  sutures,  it  is  always  best 
to  take  those  from  the  top  of  the  tail,  where  they  have  not  been  con- 
taminated so  much  with  the  excrementitious  matter  of  the  body. 

Kangaroo  ligatures  are  made  from  the  smaller  tendons  of  the  kan- 
garoo's tail.  They  are  stronger  than  catgut,  but  not  so  rapidly  ab- 
sorbed. 

Silkworm-gut  is  made  from  the  thin,  thread-like  material  drawn 
from  the  silkworm  which  has  been  killed  when  ready  to  spin  its  cocoon. 
This  material  and  silk  thread  are,  under  favorable  circumstances,  some- 
times absorbed,  but  the  process  is  much  slower  than  with  catgut  and 
other  animal  ligatures. 

Silver  wire  is  occasionally  used  for  the  ligation  of  arteries;  when 


LIGATURES,    SUTURES,    AND    SUTURING. 


149 


used  for  this  purpose  the  ends  are  cut  short,  and  the  wire  is  allowed  to 
remain  and  become  encysted. 

Ligation  of  Vessels. — Ligation  of  bleeding  vessels  is  the  most 
important  of  all  the  measures  employed  for  the  arrest  of  hemorrhage. 

This  operation  consists  of  seizing  the  end  of  the  bleeding  vessel 
with  the  hemostatic  forceps  (Figs.  38,  39),  lifting  it  from  its  bed  and 
passing  the  ligature  around  the  vessel  at  the  point  of  the  forceps,  and 
tying  it  tightly  with  a  square  or  surgeon's  knot  (Fig.  40). 


Straight  Artery  Forceps. 

Fig.  39. 


Curved  Artery  Forceps. 


Fig.  40. 


Surgeon's  Knot. 

If  the  ligature  is  to  be  buried,  the  ends  should  be  cut  short; 
if  it  is  to  be  removed  at  a  later  period  after  it  has  sloughed  off,  one  end 
should  be  left  long  enough  to  reach  outside  the  lips  of  the  wound. 

The  effect  of  a  ligature  tied  about  an  artery  is  to  divide  the  middle 
and  inner  coats,  which  curl  up  within  the  vessel, — invaginate;  the 
blood-current  is  arrested,  and  clotting  takes  place,  which  extends 
backward  to  the  first  lateral  branch. 

Plastic  lymph   is   then   deposited   about   the   ligature,   the   clot 


150 


SURGERY    OF    T-HE    FACE,    MOUTH,    AND    JAWS. 


becomes  infiltrated  with  leucocytes  and  is  organized  into  fibrous  tissue, 
and  the  artery  is  converted  into  a  fibrous  cord.  The  ligature,  if  of 
animal  tissue  and  aseptic,  is  absorbed;  otherwise  it  is  encysted. 

If  the  ligature  is  septic,  it  causes  irritation;  inflammation  with 
suppuration  and  ulceration  takes  place,  followed  by  sloughing,  and 
may  be  accompanied  by  secondary  hemorrhage. 

All  ligatures,  of  every  description,  should  be  rendered  aseptic  by 
treatment  with  antiseptic  solutions,  or  by  boiling. 

Sutures  and  Suturing. 
Definition. — Suture  (Lat.  suere,  to  sew).    "Suturing  is  the  opera- 
tion or  procedure  of  stitching  parts  together,  particularly  the  lips  of  a 
wound.     The  thread  or  other  like  material,  together  with  the  method 
of  inserting  it,  in  the  operation  of  stitching  parts  together." 


Fig 


Hagedorn  Nerdles. 


Numerous  forms  of  needles  are  used  by  surgeons,  each  adapted 
to  its  special  purpose,  or  to  conform  to  the  fancy  of  the  operator. 
For  accessible  wounds,  a  straight  needle  is  most  convenient;  but 
where  they  are  less  accessible,  it  is  necessary  to  employ  needles  with 


LIGATURES,    SUTURES,    AND    SUTURING. 


151 


more  or  less  curvature  at  the  point,  or  even  crescent-shaped  (Figs.  41, 

42,  43)- 

A  good  needle-holder  is  very  essential  in  the  suturing  of  wounds, 

and  it  must  be  adapted  to  the  form  of  needle  to  be  used.  Figs.  44,  45, 
are  forms  in  common  use;  Fig.  46  is  a  new  instrument  devised  by 
Dr.  Belknap. 

Fig.  42. 


Curved  Needles. 


The  common  methods  of  suturing  for  closing  wounds  or  stitching 
divided  soft  structures  together,  are — 

ist.  The  Continuous  or  Glover's  Suture.— By  this  method  the 
wound  is  closed  with  one  continuous  thread,  after  the  manner  of  the 
glover's  stitch  or  the  tailor's  whip-stitch,  or  overhand.  The  needle 
being  armed  with  a  single  or  double  thread,  as  desired,  is  passed 
through    both  lips  of  the  wound  from  side  to  side,  and  the  first  stitch 


152 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


tied;  then  the  needle  is  passed  in  the  same  manner  as  at  first,  ahvays 
entering  in  the  same  side,  and  tying  the  last  stitch  when  completed 
(Fig.  47). 

2d.     The  Interrupted  Suture. — In  approximating  divided  surfaces 
by  this  method,  the  needle  is  passed  through  both  lips  of  the  wound, 

Fig.  44. 


Needle  Holders. 

Fig. 


Belknap  Needle  Holder. 


Fig.  47- 


Continuous  Suture. 


and  each  stitch  tied  before  another  is  placed  (Fig.  48).  This  is  the 
form  of  suture  most  commonly  employed  with  all  suture  materials 
except  metallic  wires. 

5^.     The  Pin  Suture. — This  form  of  suture  is  better  known  as  the 
hare-lip  or  twisted  suture,  as  it  is  more  frequently  used  in  closing  hare- 


LIGATURES,    SUTURES,    AND    SUTURING. 


153 


lip  than  in  any  other  operation.  It  consists  of  passing  long,  slender 
metallic  pins  through  the  lips  of  the  wound,  and  securing  apposition  by 
winding  a  silk  thread  under  the  exposed  and  opposite  ends  of  the  pin 
(Fig.  49).  The  thread  may  be  carried  in  the  form  of  an  ellipse,  or  the 
figure  8,  and  finally,  in  either  case,  from  one  pin  to  the  other,  in 
order  the  more  completely  to  cover  the  edges  of  the  wound.  The 
points  of  the  pins  must  be  cut  off  with  a  pair  of  nippers,  after  the 
suture  is  tied.  Rubber  bands  are  sometimes  used  instead  of  the 
thread. 

Fig.  48.  Fig.  49. 


Interrupted  Sutlre. 

Fig.  ;o. 


Pin  Suture. 


Fig.  ;i. 


Quilled  Suture  Completed. 


Quilled  Suture. 

4th.  The  Qidlled  Sittiire. — Double  threads  are  passed  across  the 
wound  at  some  little  distance  from  the  edges,  and  quite  deeply,  includ- 
ing the  skin  and  other  tissues.  One  end  of  the  thread  is  looped  over  a 
quill,  or  a  section  of  soft,  elastic  catheter,  on  the  one  side,  and  the  other 
free  end  drawn  tightly  and  tied  over  the  quill  upon  the  opposite  side 
(Figs.  50,  51).  Superficial  stitches  are  usually  inserted  between  the 
quilled  sutures. 


154 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


^th.  The  Clamp  Suture. — This  suture  is  a  modification  of  the 
quilled  suture.  Strips  of  lead,  having  holes  punched  through  them 
at  the  proper  intervals,  are  used  instead  of  the  quills,  the  thread  being 
passed  through  the  holes  in  the  lead,  and  tied  upon  opposite  sides. 

6th.  The  Button  Suture. — This  is  also  a  modification  of  the  quilled 
or  the  clamp  suture.  Wire  is  passed  across  the  bottom  of  the  wound, 
brought  out  at  some  distance  from  the  edges,  and  secured  by  fastening 
to  leaden  buttons,  having  holes  punched  through  them  (Fig.  52), 
The  quill,  clamp,  and  button  sutures  are  employed  where  the  loss  of 
tissue  has  been  considerable,  to  prevent  tension  upon  the  superficial 
stitches,  and  are  termed  sutures  of  relaxation.     When  the  wound  is 


Fig.  52. 


Button  Suture. 


Cobbler's  Suture. 


Fig.  54. 


Shotted  Suturh. 

deep,  interrupted  sutures  are  passed  through  the  tissues  near  the 
bottom  of  the  wound,  and  brought  out  at  some  distance  from  the 
edges.     These  are  termed  sutures  of  approximation. 

The  superficial  sutures  with  which  the  skin,  or  other  external 
surfaces,  are  accurately  joined,  are  termed  sutures  of  coaptation. 

yth.  The  Buried  Suture. — This  form  of  suture  is  employed  to  ap- 
proximate structures  in  the  deep  portions  of  wounds.  The  suture  is 
usually  passed  horizontally  through  the  sides  of  a  wound,  and  tied,  the 
superficial  tissues  being  brought  together  over  it.  Buried  sutures  are 
always  completely  covered  by  the  skin,  and  do  not  enter  this  structure 
at  all. 

8th.     The  Cobbler's  Suture. — This  is  a  continuous  suture;  armed 


LIGATURES,    SUTURES,    AND    SUTURING.  I55 

with  two  needles,  the  lips  of  the  wound  or  denuded  surface  being 
brought  together  by  a  back-and-forth  stitch,  with  first  one  needle  and 
then  the  other  (Fig.  53).  This  is  a  favorite  suture  with  the  writer  for 
uniting  the  denuded  surfaces  of  the  subperiosteal  flaps  in  urano- 
plasties. 

pth.  The  Shotted  Suture. — This  suture  is  of  silver  wire,  which  is 
passed  through  both  lips  of  the  wound,  or  the  edges  to  be  united  and 
twisted;  a  perforated  leaden  shot  is  then  threaded  upon  both  ends  of 
the  wire,  and  carried  downward  until  the  lips  of  the  wound  are  approx- 
imated, and  then  it  is  tightly  compressed  upon  the  wire,  and  the  wire 
cut  close  to  the  shot  (Fig.  54).  This  form  of  suture  is  frequently  used 
for  uniting  the  edges  of  a  cleft  palate. 

Sutures,  as  a  rule,  should  be  removed  on  the  fourth  or  fifth  day, 
when  employed  about  the  face,  except  in  those  cases  where  there  is 
danger  of  gaping  of  the  wound;  and  even  in  these,  by  a  judicious  use 
of  adhesive  plaster,  or  gauze  and  collodion,  this  danger  may  be  suc- 
cessfully guarded  against.  A  safe  rule  to  follow  is  always  to  remove 
the  sutures  upon  the  first  observable  tendency  to  irritation.  Suppura- 
tion must  always  be  guarded  against,  as  this  process  invariably  pro- 
duces a  cicatrix. 

In  operations  for  cleft  palate  where  silver  wire  sutures  are  em- 
ployed, they  are  sometimes  allowed  to  remain  from  eight  to  ten  days, 
provided  no  irritation  is  produced  by  their  presence. 

By  the  use  of  aseptic  sutures,  dressings  and  solutions,  and  anti- 
septic pre-operative  and  after-treatment,  the  dangers  from  suppuration 
are  reduced  to  the  minimum. 


PART  II. 

CHAPTER    XVII. 

WOUNDS. 

Wound  (A.  S.  zvtmd,  a  wound). 

Definition. — A  zvound  is  a  break  or  division  of  continuity  of  the 
soft  parts,  caused  by  mechanical  violence, — a  trauma. 

"Solutions  of  continuity  may  occur  in  any  of  the  tissues  of  the 
body  from  slowly-acting  causes  operating  within  the  body  itself,  like 
the  process  of  ulceration,  or  the  gradual  wasting  of  atrophy."  Such  a 
breach  in  the  continuity  of  the  tissues,  however,  would  not  be  classed 
as  a  wound.  In  the  idea  of  wounds  there  is  involved  the  action  of 
some  force  outside  of  the  body  which  has  caused  a  division  or  break  in 
the  tissues  by  violence.  But  even  with  this  somewhat  restricted  defini- 
tion of  a  wound,  the  term  has  yet  a  very  wide  range  of  applicability. 
All  solutions  of  continuity,  therefore,  the  result  of  violence  from  ex- 
ternal forces,  such  as  contusions,  sprains,  fractures,  punctures,  lacera- 
tions, incisions,  etc.,  of  any  of  the  external  or  internal  tissues  or  organs 
of  the  body,  would  be  termed  wounds.  All  traumatic  injuries  are 
essentially  identical  in  that  the  same  process  of  repair  is  involved  in  the 
healing  of  all  of  them,  and  they  are  subject  to  the  same  general  prin- 
ciples of  treatment,  the  application  of  which  is  regulated  by  the  struc- 
ture of  the  tissue,  its  means  of  nutrition,  its  particular  function,  its 
relationship  to  surrounding  tissues,  and  the  character  and  extent  of 
the  injury. 

Classification. — All  wounds  may  be  divided  into  two  general 
classes,  viz :  open  and  subcutaneous  wounds.  To  the  first  class  belong 
all  wounds  which  are  accompanied  by  a  break  in  the  external  tissues, 
while  under  the  second  may  be  grouped  all  those  injuries  to  the  sub- 
cutaneous tissues  which  are  caused  without  a  solution  of  the  continuity 
of  the  skin  or  mucous  membrane. 

Wounds  are  also  classified  as  superacid  and  deep,  simple  and  com- 
plicated. They  are  superficial  when  the  skin  or  mucous  membrane  only 
is  involved;  deep  when  the  underlying  tissues  are  implicated;  simple 
when  the  soft  parts  are  divided  without  complication  of  any  kind;  com- 
plicoted  when  a  foreign  body  or  substance  is  present,  or  when  there  is 

157 


158  SURGERY    OF    THE    FACE,    MOUTH,    AND   JAWS. 

considerable  hemorrhage  or  pain.  Wounds  are  termed  incised  when 
caused  by  a  cutting  instrument;  lacerated  when  the  tissues  are  torn; 
contused  when  bruised  or  crushed  with  a  bhmt  instrument  or  heavy 
weight;  punctured  when  made  with  a  pointed  instrument;  poisoned  when 
some  toxic  substance  has  been  introduced,  hke  dissecting  wounds,  the 
bite  of  a  rabid  dog  or  of  a  venomous  snake. 

A  gunshot  wound  is  one  which  has  been  made  by  a  projectile. 
Penetrating  wounds  are  those  in  which  the  missile  enters  the  body  with- 
out emerging.  Perforating  wounds  are  those  in  which  the  missile 
both  enters  into  and  emerges  from  the  body. 

A  surgical  wound  is  one  which  has  been  made  in  the  performance 
of  a  surgical  operation. 

A  -flesh  wound  is  one  in  which  the  skin  and  muscular  tissues  only 
are  involved. 

An  open  wound  is  one  having  a  free  external  opening  or  breach  of 
the  skin  or  mucous  membrane, 

A  closed  wound  is  one  having  no  external  opening,  or  when  the 
wound  has  been  brought  together  with  sutures. 

A  subcutaneous  wound  is  one  in  which  the  tissues  beneath  the  skin 
or  mucous  membrane  have  been  torn  or  lacerated,  and  the  external 
tissues  have  remained  intact.  Subcutaneous  wounds  generally  heal 
without  suppurative  inflammation,  as  the  unbroken  external  tissues 
protect  them  from  outside  forms  of  irritation  and  from  infection. 

Wounds  may  be  again  classed  according  to  their  septic  or  aseptic 
condition.  Septic  wounds  include  all  those  traumatic  injuries  which 
have  become  infected  with  the  micro-organisms  which  cause  fermenta- 
tion or  putrefaction,  like  the  pus-microbes  or  the  saprophytic  germs. 
Such  wounds  are  always  accompanied  by  a  considerable  degree  of 
inflammation,  suppuration,  and  sloughing  of  dead  tissue;  the  amount 
of  dead  tissue  thus  thrown  ofif  depending  upon  the  extent  and  severity 
of  the  primary  injury  and  the  character  of  the  inflammation. 

Aseptic  wounds  include  all  traumatic  injuries  which  have  escaped 
infection  by  micro-organisms  or  their  products.  The  aseptic  condi- 
tion may  be  the  result  of  the  resistance  of  the  tissues  to  the  growth  and 
development  of  the  micro-organisms  which  may  have  gained  access 
to  the  wound;  or  of  the  protection  which  the  wound  received  at  the 
time  of  its  infliction,  against  the  entrance  of  septic  agents;  or  of  the 
application  of  agents  which  removed  or  destroyed  them  and  afterward 
prevented  their  ingress. 

Healing  of  Wounds. — The  process  of  repair  or  regeneration  of 
tissues,  constantly  going  on  in  the  living  human  body,  is  a  physiolog- 
ical function,  intended  to  replace  the  normal  waste  of  tissue,  and  to 
restore  tissues  which  have  been  lost  by  injury  or  disease.  In  the  full- 
grown  bodv  the  waste  incident  to  a  healthv  activitv  is  balanced  bv 


WOUNDS.  159 

the  reparative  process,  but  during  the  period  of  the  development  of  the 
body  the  material  appropriated  by  the  tissues  is  largely  in  excess  of  the 
physiological  waste.  This  increase  in  the  material  appropriated  by  the 
tissues  constitutes  growth  or  physical  development.  When  waste 
of  tissue  is  in  excess  of  cell-production,  atrophy  is  the  result;  e.g., 
general  emaciation  on  the  one  hand,  and  atrophy  of  certain  groups  of 
muscles  on  the  other,  the  result  of  neurotic  disturbance,  are  marked 
illustrations. 

When  the  process  of  regeneration  is  completely  suspended,  death 
must  soon  follow  as  a  natural  consequence. 

The  blood  is  the  first  tissue  to  be  affected  by  any  marked  change 
in  the  equilibrium  between  waste  and  repair.  The  other  tissues  soon 
suffer  in  a  degree  proportionate  to  the  diminution  in  the  function  of 
nutrition,  and  finally  death  results  from  marasmus. 

Before  the  introduction  of  antiseptic  treatment  of  wounds  it  was 
supposed  that  inflammation  was  necessary  for  the  regeneration  of 
injuries  or  lost  tissues,  but  since  it  has  been  discovered  that  wounds 
in  a  state  of  asepsis  heal  without  the  usual  phenomena  of  inflam- 
mation, the  processes  of  repair  and  that  of  inflammation  have  been 
regarded  as  entirely  distinct  from  each  other. 

The  process  of  repair  in  aseptic  wounds  is  brought  about  by 
means  of  an  increased  activity  in  cell-production,  or  multiplication  of 
the  tissue-cells,  which  enables  them  to  replace  tissues  which  have 
been  lost  or  destroyed.  The  regeneration  of  tissue  in  the  healing  of 
wounds  is  accompanied  by  indirect  cell-division  or  karyokinesis  of  the 
fixed-tissue  cells  of  the  injured  part.  The  old  theory  of  cell-prolif- 
eration assumed  that  all  cells  underwent  segmentation  of  the  nucleus 
and  division  of  the  protoplasm  by  what  is  called  direct  cell- division. 
The  latter  process  is  now  thought  to  be  confined  to  those  cells  which 
do  not  possess  the  power  of  forming  new  tissues;  as,  for  instance,  the 
leucocytes,  which  take  no  prominent  part  in  the  process  of  repair,  but 
rather  serve  as  nutrient  media  for  the  forming  tissues. 

According  to  the  most  recent  investigations  into  the  process  of 
cell-multiplication,  or  karyokinesis,  it  has  been  shown  (Ziegler)  that  the 
process  is  attended  with  peculiar  changes  in  the  cell  and  its  nucleus. 
The  first  signs  which  are  made  manifest  that  cell-division  is  about  to 
take  place  are  certain  changes  in  the  nucleus  which  finally  result  in 
subdivision.  Later  the  protoplasm  takes  on  active  changes,  influ- 
enced, seemingly,  by  the  activity  of  the  nucleus,  which  eventuates  in 
the  complete  subdivision  of  the  cell  into  two  equal  portions,  each  com- 
plete in  itself. 

These  changes,  according  to  Flen>ming  (Ziegler),  take  place  in 
the  following  order:  The  first  stage  in  the  process  of  division  of  the 
nucleus  is  the  disappearance  of  the  nuclei,  while  the  substance  of  the 


i6o 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


nucleus  assumes  the  form  of  a  mass  of  sinuous  filaments  or  a  raveled 
coil,  which  is  termed  the  coil-form  of  the  mother  nucleus.  From  this 
stage  in  the  process  the  nuclear  substance  alone  is  susceptible  to  the 
action  of  staining  reagents,  and  for  this  reason  the  nuclear  substance 
has  been  termed  chromatin  (Fig.  55). 

The  filaments  now  become  thicker  and  the  coil  looser;  breaks 
occur  in  its  continuity,  and  it  gradually  passes  into  a  wreath-like  form. 
The  arrangement  of  the  filaments  is  in  a  series  of  loose  central  and 

Fig.    55- 


K 


Cells  from  the  Epidermis  of  Very  Young  Larva  of  Newt.  (After  Piersol.) 
A,  resting  nucleus  ;  £,  close  skeins  ;  C,  loose  skeins  ;  D  and  E,  mother  stars,  seen  from  the  polar 
field  and  appearing  as  the  wreath  stage  ;  r,  mother  star  from  the  side ;  C,  migration  of  segments  ; 
H,  daughter  stars  ;  /and/,  segments  grouped  about  new  polar  fields  (in /this  protoplasm  exhibits 
constriction)  ;  K,  daughter  skeins  (division  of  nucleus  complete,  with  slight  constriction  of  cell- 
body)  ;  L,  complete  division  of  nucleus  and  protoplasm. 

peripheral  loopings  with  the  center  of  the  mother  nucleus  unoccupied. 
The  next  change  of  the  nucleus  is  from  the  wreath-like  arrangement  of 
the  filaments  to  that  of  a  star-form  or  asterisk,  with  double  rays,  and 
the  peripheral  loops  later  divided  at  their  free  extremities.  Following 
this  the  double  rays  divide  longitudinally,  and  a  considerable  contrac- 
tion of  the  whole  star-form  takes  place.  The  single-rayed  star  thus 
formed  next  divides  through  the  equator  into  two  equal  polar  seg- 
ments. This  division  is  accompanied  by  the  formation  of  a  transpar- 
ent equatorial  plate  (Strasburger's  cell-plate),  which  is  often  marked 
by  a  line  of  five  points.     Later  the  polar  segments  move  asunder 


WOUNDS. 


i6i 


toward  opposite  poles,  and  assume  an  appearance  resembling  a  "half- 
barrel"  or  a  "basket  form."  These  now  represent  the  daughter  nuclei, 
which  soon  pass  into  the  star-form,  and  this  into  the  wreath-form,  by  a 
fusion  of  the  ends  of  the  star-rays.  At  the  same  time  a  constriction  of 
tlie  cell-protoplasm  commences.  The  wreath-form  of  the  daughter 
nuclei  now  shrinks,  and  its  filaments  become  more  and  more  sinuous, 
until  it  assumes  the  coil-form.  The  constriction  of  the  cell-protoplasm 
has  also  by  this  time  been  completed.  In  the  last  stage  the  coil-form 
becomes  more  loose  and  regular,  and  finally  develops  into  the  nuclear 
network  or  reticulum,  like  that  of  the  mother  nucleus. 

Fig.  s6. 


Karyokinesis— Loose  Skein.    X  1500. 

The  severance  of  the  cell-protoplasm  completes  the  process  of 
karyokinesis,  and  the  new-formed  nuclei  enter  the  resting  state  corre- 
sponding to  the  resting  state  of  the  mother  nucleus.  During  the  pro- 
cess of  subdivision  the  nucleus  is  surrounded  by  a  clear  intermediate 
substance.  This  substance  during  the  active  stages  of  subdivision  is 
not  susceptible  to  staining  reagents,  but  in  the  resting  state  it  is  readily 
stained.  Figs.  56,  57,  58,  are  photo-micrographs  of  the  three  principal 
stages  in  the  process  of  karyokinesis, — the  formation  of  the  loose 
skein,  the  equatorial  plate,  and  the  separation  into  daughter  asters  or 
stars;  the  outline  of  the  cell-protoplasm  being  distinctly  seen. 

Sometimes  segmentation  of  the  nucleus  takes  place  without  sub- 
division of  the  cell-protoplasm,  thus  forming  a  binucleated  cell;  or  if 
the  process  of  segmentation  goes  on,  a  multi-nucleated  or  giant  cell  is 
formed.     The  giant  cells,  however,  may  later  break  up  into  uninu- 


1 62 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


cleated  cells,  the  protoplasm  gathering  around  the  individual  nuclei 
and  dividing  along  the  boundaries  so  defined. 


Fig.  57. 


Karyokinesis- Equatorial  Plate.    X  1500. 
Fig   58. 


Karyokinesis— Daughter  Asters.     X  i5°°- 


Regeneration  of  tissue  includes  the  reparative  process  which  takes 
place  in  the  healing  of  traumatic  wounds,  and  the  reproduction  of 
tissue  lost  from  inflammatory  processes. 


WOUNDS.  163 

All  reparative  processes  are  brought  about  by  cell-proliferation, 
"each  after  its  kind."  This  is  a  histogenetic  law  which  has  been 
abundantly  demonstrated,  and  generally  accepted.  Every  normal  cell 
is  endowed  with  an  inherent  tendency  to  reproduce  itself,  and  to  trans- 
mit its  own  peculiar  function  of  tissue-building.  This  function  is 
never  perverted  to  the  production  of  a  tissue  with  a  materially  different 
histologic  structure,  but  always  reproduces  a  tissue  which  is  anatomi- 
cally and  physiologically  like  the  tissue  of  which  it  formed  a  part. 
Nerve-cells  produce  nerve-cells;  epithelial  cells  are  only  produced  by 
epithelial  cells;  bone-cells  by  bone-cells;  enamel-cells  by  enamel-cells, 
etc. 

All  wounds,  whatever  their  anatomical  structure,  heal  by  cell-pro- 
liferation,— by  the  production  of  new  material  from  the  fixed-tissue 
cells  of  the  immediate  neighborhood. 

The  fixed-tissue  cells  being  endowed  with  the  power  of  adaptation 
to  conditions  which  surround  them,  begin,  immediately  after  the  injury 
has  been  received,  to  inaugurate  the  process  of  repair.  This  consists 
of  rapid  segmentation  of  the  pre-existing  tissue-cells,  thus  forming 
embryonal  cells;  these  cells  gradually  assume  the  character  of  mature 
cells,  as  the  process  of  healing  progresses,  until  finally  they  represent 
the  tissues  from  which  they  had  their  origin. 

Methods  of  Healing. — The  processes  by  which  wounds  heal  are 
generally  classed  under  three  heads:  First,  union  by  primary  adhesion, 
or  first  intention;  second,  adhesion  by  granulation,  or  second  intention; 
third,  secondary  adhesion,  or  third  intention. 

Healing  by  Primary  Adhesion^  or  First  Intention. — To  secure  union 
by  this  process  the  surfaces  of  the  wound  must  be  accurately  approxi- 
mated, and  shielded  from  all  forms  of  irritation.  Under  such  circum- 
stances the  exudate  will  be  of  minimum  quantity,  and  absorption  of  the 
red  blood-corpuscles  will  occur;  at  the  expiration  of  twenty-four  hours 
adhesion  between  the  surfaces  has  taken  place,  and  at  the  end  of  two 
or  three  days  the  new-formed  material  (plastic  lymph)  which  binds 
them  together  will  be  traversed  by  blood-vessels. 

John  Hunter  believed  that  the  process  of  primary  union  might 
be  accomplished  in  a  few  hours  in  incised  wounds  where  perfect  coap- 
tation of  the  parts  could  be  secured,  without  the  interposition  of  new 
material.  He  has  been  supported  in  these  views  by  Macartney  and 
Sir  James  Paget,  and  later,  among  the  more  modern  pathologists  and 
surgeons,  we  find  Thiersch  holding  the  same  views. 

The  process  of  primary  or  immediate  union  is  usually  accomplished 
with  only  the  slightest  manifestations  of  inflammation,  rarely  pro- 
gressing beyond  a  little  hyperemia,  puffiness,  and  tenderness  about 
the  edges  of  the  wound,  and  leaves  little  or  no  scar. 

In  primary  union  there  is  restoration  of  continuity,  a  coaptation  of 


164 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


divided  tissues,  part  with  part, — an  organic  union,  vessel  with  vessel, 
and  nerve  with  nerve.  In  deep  wounds,  where  important  nerve-trunks 
are  severed,  it  is  necessary  to  bring  the  divided  ends  of  the  nerve  to- 
gether by  suturing,  and  some  surgeons  maintain  that  nerve  function  is 
occasionally  restored  in  a  few  hours  after  this  operation. 

Restoration  of  function  in  the  circulation  and  nerve-supply,  even 
under  the  most  favorable  circumstances  that  can  possibly  surround  an 
incised  wound,  rarely  occurs  under  six  to  eight  days.  Wounds  which 
heal  by  first  intention  are  always  aseptic. 

Fig.    59. 


Fibroblasts. 


Fibroblasts. 


Fibrinous 
exudate. 


Inflammation— SHOWING  Fibroblasts  in  Regeneration  of  Tissue.    ,,<  50. 

Healing  by  Second  Intention,  or  Adhesion  by  Gramdation. — This 
process  takes  place  in  those  wounds  in  which  the  surfaces  have 
not  been  accurately  brought  together,  or  have  been  subjected  to  irrita- 
tion of  a  mechanical,  chemical,  or  septic  nature.  Under  these  cir- 
cumstances the  exuded  material  becomes  excessive,  death  of  the  blood- 
cells  and  the  newly-formed  embryonal  cells  takes  place,  resulting  in 
suppuration.     On  the  removal  of  the  source  of  irritation,  the  inflam- 


WOUNDS. 


165 


matory  process  quickly  subsides,  and  is  immediately  followed  by  cell- 
proliferation,  which  soon  fills  the  gap  with  granulations,  and  later 
covers  the  surface  with  a  modified  epithelial  structure  which  forms  a 
scar.  During  the  formation  of  the  granulation-tissue,  the  fixed-tissue 
cells  are  in  an  active  state  of  multiplication  by  subdivision,  and  from 
these  embryonic  cells  the  new  tissue  is  formed  to  replace  that  which 
has  been  lost  (Fig.  59). 

Fig.    60. 


Fibroblasts 


Blood-vessels. 


Inflammation— SHOWING  Fibroblasts  and  Vascularization  in  Granulation-Tissue.    X  50. 


Ziegler  defines  granulation-tissue  as  "a  structure  fashioned  out  of 
the  cellular  material  gathered  by  the  blood  from  the  system  in  general, 
and  utilized  to  make  good  a  defect  which  the  fixed-tissue  cells  of  the 
injured  region  are  unable  to  repair."  The  tissue  formed  by  the  pro- 
cess of  granulation  is  cicatricial  tissue,  and  is  devoid  of  all  specialized 
structures  except  blood-vessels.  (Fig.  60.)  All  specialized  tissues 
like  epithelium,  muscles,  bones,  nerves,  and  blood-vessels  can  be  repro- 
duced only  by  a  regenerative  cell-proliferation  of  identical,  pre-exist- 
ing tissues.     None  of  these  can  be  reproduced  from  granulation-tissue. 


l66  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

Healing  by  Third  Intention,  or  Adhesion  of  Granulating  Sur- 
face.— This  process  takes  place  in  amputation  flaps  which  have  failed 
to  unite  by  first  intention,  in  large  abscess-cavities  where  it  is  impos- 
sible to  bring  the  walls  together,  and  in  those  cases  where  large  por- 
tions of  tissue  have  been  lost  by  gangrene  or  traumatisms.  In  this 
form  of  healing,  the  granulation-tissue  reaches  out  from  all  surfaces  of 
the  wound,  gradually  encroaching  upon  the  space  until  they  meet  and 
unite.  The  process  of  healing  may  extend  over  weeks  and  months, 
depending  upon  the  character  and  extent  of  the  tissue  to  be  restored 
and  the  condition  of  the  wound.  Under  a  strict  antiseptic  regime  such 
wounds  heal  much  more  readily  than  when  these  precautions  are 
omitted.  The  extent  of  the  scar  will  depend  upon  the  character  of  the 
tissue  which  has  been  lost  and  the  amount  of  tissue  to  be  restored. 

Senn  classes  all  forms  of  healing  under  two  heads, — Union  by 
Primary  Intention,  and  Union  by  Secondary  Intention.  The  first  he 
would  have  include  all  wounds  which  heal  without  septic  manifesta- 
tions; in  other  words,  all  aseptic  wounds,  no  matter  whether  they  heal 
in  three  or  four  days,  or  require  as  many  months;  while  in  the  other 
class  he  would  place  all  wounds  which  have  given  evidence  of  septic 
inflammation.  He  does  not  believe  it  is  correct,  from  a  pathologic 
or  from  a  practical  standpoint,  to  class  aseptic  wounds,  which,  on  ac- 
count of  failure  of  approximation  or  loss  of  tissue,  must  heal  by  granu- 
lation, with  infective  wounds,  in  which  the  reparative  process  has  been 
disturbed  and  retarded  by  suppuration. 

Surgical  Cleanliness. — Absolute  cleanliness  in  surgical  operations 
is  of  such  great  importance  in  the  successful  treatment  and  final  issue 
of  all  surgical  cases,  that  too  much  stress  cannot  be  laid  upon  its  strict 
observance  in  every  detail.  The  student  particularly  needs  to  be  im- 
pressed at  the  very  outset  of  his  studies  in  surgery,  not  only  with  the 
fact  that  wounds  do  better  when  such  precautions  have  been  taken, 
but  that  the  dangers  to  life  from  complications  arising  from  septic 
infection  are  thereby  reduced  to  the  minimum.  The  question  of  the 
value  of  asepsis  and  antisepsis  in  all  surgical  operations,  and  in  the 
treatment  of  all  surgical  diseases,  is  no  longer  one  of  controversy.  The 
statistics  of  surgical  operations  of  all  kinds  before  the  days  of  Lister, 
contrasted  with  those  of  the  last  two  decades,  are  the  best  proof  of  the 
value  of  asepsis  and  antisepsis  in  surgery.  The  best  surgeons  the 
world  over  admit  their  value,  and  attempt  as  far  as  possible  to  carry 
out  the  principles  of  this  method  of  treatment.  The  laboratory  proofs 
that  suppuration,  septicemia,  pyemia,  erysipelas,  and  kindred  dangers 
arise  from  the  pyogenic  micro-organisms  are  now  considered  so  com- 
plete that  no  really  unbiased  mind  can  doubt  them,  while  the  clinical 
proofs  are  equally  convincing.  Success  does  not  always  perch  upon 
the  banners  of  the  most  brilliant  surgeons,  but  rather  upon  the  stand- 


WOUNDS.  167 

ard  of  him  who  is  the  most  careful  and  painstaking,  and  whose  tech- 
nique is  most  perfect  in  all  its  details.  Carelessness  in  some  appar- 
ently minor  matter  may  ruin  an  otherwise  successful  operation,  or 
endanger  the  life  of  the  patient.  Cleanliness,  above  all  things,  is 
necessary  to  a  successful  treatment  of  wounds.  Not  ordinary  clean- 
liness, in  its  general  acceptation,  but  surgical  cleanliness,  and  there  is 
a  vast  diflference  between  them.  To  be  surgically  clean  means  to  be 
germ-free. 

The  part  to  be  operated  upon  must  be  freed  from  micro-organisms 
bv  thorough  washing  with  soap  and  water,  and  irrigating  with  anti- 
septic solutions.  The  hands  of  the  operator,  assistants,  and  nurses 
must  be  cleansed  in  a  like  manner,  and  the  accumulations  under  the 
finger-nails  removed.  This  should  be  done  before  bathing  them  in  the 
antiseptic  solutions.  All  instruments  must  be  first  scrubbed  with  soap 
and  water,  and  then  boiled  in  water.  The  ligatures  and  the  drainage- 
tubes  should  be  kept  in  antiseptic  solutions,  and  the  sponges  and  dress- 
ings of  every  kind  sterilized  by  heat  and  antiseptics. 

By  following  such  a  regime  as  this,  all  wounds  capable  of  being 
protected  against  the  entrance  of  micro-organisms  or  other  foreign 
elements  will  heal  without  inflammatory  symptoms,  provided  they  are 
shielded  from  mechanical  irritation  from  the  sutures  and  dressings,  and 
the  general  health  of  the  individual  is  fairly  good. 

Wounds  sometimes  do  badly  from  defective  nutrition,  either  local 
or  general.  The  former  is  usually  caused  by  tension  or  a  bad  posi- 
tion. These  can  easily  be  remedied.  But  it  may  occur  as  a  result  of 
the  necessary  ligation  or  injury  of  some  important  artery,  and  failure 
in  the  establishment  of  an  adequate  collateral  circulation. 

General  defective  nutrition  is  the  result  of  a  debilitated  condition 
of  the  system,  arising  from  illness,  insufficient  or  improper  food,  or 
excesses,  particularly  the  drink  habit.  As  a  rule,  fractures  of  the  bones 
do  not  unite  as  readily  in  the  confirmed  drunkard  as  in  other  persons, 
and  injuries  to  the  tissues  are  much  more  liable  to  result  in  gangrene 
and  necrosis. 


CHAPTER    XVIII. 
TREATMENT  OF  WOUNDS. 

The  Treatment  of  Wounds  consists  of — 

First.     Asepsis. 

Second.     The  arrest  of  hemorrhage. 

Third.     Accurate  approximation  of  the  divided  surfaces. 

Fourth.     Providing  for  drainage. 

Fifth.     Physiological  rest. 

Sixth.     Proper  dressings. 

Fig.  6i. 


Various  Forms  of  Bacteria  from  the  Mouth. 
fl,  c,^,  screw-forms  ;  6,  cocci;  rf,  rods;  f,  coccus-chain  with  sheath  ;  ?',  coccus-chain  (streptococci) 
^,  rod-chain ;  A,  various  thread-forms.     (After  Miller.) 

Asepsis. — The  first  consideration  in  the  treatment  of  all  wounds 
is  that  of  establishing  aseptic  conditions.  To  accomplish  this  end,  the 
wound  must  be  freed  from  all  extraneous  substances  and  foreign 
bodies,  and  thoroughly  irrigated  with  antiseptic  solutions.  When  the 
wound  is  upon  the  external  surface  of  the  body,  the  skin  about  the 
injured  part  should  be  carefully  cleansed  with  soap  and  water;  if  hair 


TREATMENT    OF    WOUNDS.  169 

be  present,  it  should  be  removed  with  a  razor,  and  the  wound  again 
carefully  irrigated. 

When  the  wound  is  upon  a  mucous  surface,  the  same  precautions 
as  to  asepsis  should  be  rigidly  carried  out;  and  when  associated  with 
the  oral  cavity,  a  determined  effort  should  be  made  to  place  the  mouth 
and  teeth,  as  far  as  possible,  in  an  aseptic  condition;  but  this  is  not  an 
easy  task  in  those  cases  where  the  words  oral  hygiene,  or  their  equiva- 
lent, have  formed  no  part  of  the  vocabulary  of  the  individual. 

The  removal  of  the  salivary  calculus  and  deposits  of  food  upon  the 
teeth,  and  a  thorough  irrigation  of  the  mouth  with  suitable  antiseptic 
solutions,  is  the  only  proper  method  of  rendering  this  cavity  approx- 
imately germ-free;  approximately,  because  absolute  sterilization 
would  be  impossible  of  accomplishment  with  solutions  that  would  not 
cause  serious  irritation  to  the  mucous  membrane,  and  though,  meta- 
phorically speaking,  rivers  of  these  solutions  were  turned  through  it. 
still  it  would  not  be  germ-free.  Fig.  6i  shows  some  of  the  various 
forms  of  bacteria  found  in  the  human  mouth. 

Triolo  is  authority  for  the  statement  that  fresh  sterile  saliva  will 
kill  all  the  germs  of  the  staphylococcus  aureus,  the  bacteria  of  the  air, 
of  diphtheria,  typhus,  etc.,  in  five-day  cultures,  and  greatly  reduce  their 
numbers  in  eighteen-hour  cultures,  but  that  filtered  saliva  has  no  bac- 
tericidal power. 

Wounds  of  the  soft  tissues  of  the  mouth,  in  healthy  persons  of 
cleanly  habits,  very  rarely  suppurate ;  but  when  associated  with  com- 
pound fractures  of  the  jaws,  the  cases  are  rare  in  which  suppuration 
does  not  occur.  This  difference  is  largely  due  to  the  great  difficulty  in 
securing  or  maintaining  an  aseptic  condition. 

Arrestation  of  Hemorrhage. — Hemorrhage  is  from  three  sources, 
viz :  from  the  Arteries,  Veins,  and  Capillaries. 

Arterial  Hemorrhage  is  characterized  by  the  bright  red  color  of  the 
blood,  by  its  flowing  in  jets  from  the  wound,  and  by  the  arrestation  of 
the  bleeding  by  pressure  above  the  wound  upon  the  arterial  trunk. 

Venous  Hemorrhage  is  known  by  the  dark  color  of  the  blood,  its 
steady  flow,  and  its  welling  up  from  the  bottom  of  the  wound,  while 
pressure  below  the  wound,  upon  the  venous  trunk,  arrests  the  hemor- 
rhage: 

Capillary  Hemorrhage  is  recognized  by  the  oozing  of  the  blood 
from  the  surfaces  of  the  wound. 

Primary  Hemorrhage  is  the  bleeding  which  takes  place  at  the  time 
of  the  injury. 

Secondary  Hemorrhage  is  the  bleeding  which  comes  on  after  reac- 
tion is  established,  or  later,  from  the  sloughing  of  ligated  vessels  and 
other  tissues. 

Internal  Hemorrhage  is  the  bleeding  which  takes  place  in  the 
various  cavities  of  the  body. 


170  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

Extravasation  is  the  escape  of  blood  into  the  connective  tissue. 

Severe  hemorrhage  produces  marked  constitutional  effects,  char- 
acterized by  a  feeble,  fluttering,  rapid  pulse,  which  is  in  the  later  stages 
only  recognized  in  the  large  arteries.  The  lips  are  colorless,  and  the 
surface  of  the  body  is  blanched,  cold,  and  clammy.  The  respiration  is 
slow  and  sighing.  Faintness  and  nausea  are  prominent  symptoms, 
accompanied  by  great  restlessness,  roaring  in  the  ears,  and  darkness 
before  the  eyes.  A  fatal  syncope  may  follow,  or  the  patient  may 
recover.     Fever  usually  follows  recovery  from  a  severe  hemorrhage. 

Sudden  and  severe  hemorrhage  is  more  likely  to  prove  fatal  than 
one  that  is  slow  and  continuous.  Infants  are  much  more  seriously 
affected  by  the  loss  of  blood  than  older  persons. 

The  complete  arrest  of  all  hemorrhage  is  an  important  factor  in  the 
healing  of  wounds.  Blood-clots  between  the  lips  of  a  wound  are 
objectionable,  for  the  reasons:  First,  that  they  prevent  perfect  apposi- 
tion of  the  wounded  tissues;  second,  they  are  excellent  soil  for  the 
growth  of  micro-organisms;  third,  by  their  presence  they  cause  tension 
and  pain. 

There  are  various  methods  of  arresting  hemorrhage,  viz:  By 
ligation,  torsion,  pressure,  cautery,  heat,  cold,  position,  acupressure, 
forcipressure,  styptics,  and  constitutional  treatment.  The  most  com- 
mon method  of  arresting  arterial  or  venous  hemorrhage  is  by  ligation. 
This  is  accomplished  by  picking  up  the  end  of  the  bleeding  vessel  with 
the  hemostatic  forceps,  and  tying  a  ligature  around  it.  Small  arteries 
may  be  controlled  by  forcipressure — crushing  the  end  of  the  artery  by 
grasping  it  with  the  hemostatic  forceps — or  by  torsion;  this  is  accom- 
plished by  twisting  the  vessel  while  in  the  grasp  of  the  forceps.  Acu- 
pressure consists  of  passing  a  pin  or  needle  under  the  vessel,  bringing 
the  ends  of  the  instrument  above  the  external  tissues,  and  causing 
pressure  by  passing  a  ligature  around  the  ends  in  the  form  of  the 
figure  8. 

Severe  hemorrhage  should  be  checked,  when  possible,  by  pressure 
upon  the  arterial  trunk,  above  the  wound,  by  a  tourniquet,  or  an 
Esmarch  bandage  (rubber  bandage),  until  the  severed  arteries  in  the 
wound  can  be  ligated. 

In  wounds  of  the  face,  appliances  of  this  character  have  no  place; 
consequently  the  bleeding  vessels  must  be  gathered  up  and  secured  as 
quickly  as  possible  by  ligatures.  If,  however,  the  vessels  cannot  be 
reached,  as  sometimes  happens  in  compound  and  comminuted  frac- 
tures, or  following  operations  for  the  removal  of  malignant  tumors, 
etc.,  they  may  be  controlled  by  ligating  the  external  carotid  artery. 
Some  surgeons  prefer  to  take  this  precaution  prior  to  performing  any 
capital  operation  upon  the  maxillary  bones.  To  the  writer  the  latter 
procedure  does  not  seem  necessary,  for  in  his  personal  experience  the 
simpler  methods  have  always  proved  sufBcient. 


TREATMENT    OF    WOUNDS.  I7I 

Capillary  hemorrhage  may  be  controlled  by  the  application  of  a 
jet  of  cold  water  thrown  upon  the  bleeding  surfaces,  or  by  hot  water 
applied  with  sponges  or  compresses.  When  the  wound  is  in  an  ex- 
tremity, the  elevation  of  the  limb  will  often  control  this  form  of  hem- 
orrhage. If  the  foregoing  measures  fail,  then  recourse  must  be  had 
to  the  actual  cautery,  electro-thermal  cautery,  or  styptics.  The  latter, 
however,  are  to  be  avoided  when  possible,  as  they  increase  the  dangers 
of  secondary  hemorrhage,  by  causing  sloughing  of  the  cauterized 
tissues,  and  preclude  the  possibility  of  immediate  union. 

When  capillary  hemorrhage  or  oozing  is  persistent,  the  adminis- 
tration of  ergot  will  often  prove  useful  in  checking  it.  The  fluid 
extract  may  be  given  in  doses  of  20  to  30  drops  every  twenty  minutes 
until  three  doses  are  taken,  or  the  wine  of  ergot  may  be  substituted, 
dose  floj  to  ij.  Care  must  be  taken  in  administering  ergot  to  pregnant 
women  not  to  bring  on  contractions  of  the  uterus. 

Coaptation. — Accurate  approximation  of  the  surfaces  is  of  prime 
importance  in  the  JicaUng  of  zvounds,  and  the  surgeon  should  be  prepared 
not  only  to  bring  the  lips  of  the  wound  together,  but  to  unite  tissue  to 
tissue.  If  a  nerve-trunk  or  tendon  is  divided,  it  should  be  brought 
together  by  means  of  a  sterilized  animal  suture.  In  deep  wounds, 
the  lower  portions  should  be  brought  together  by  means  of  deep 
sutures, — sutures  of  approximation.  The  buried  suture  of  sterilized 
catgut  or  silk  is  also  used  to  bring  together  the  deeper  parts  of  the 
wound.  The  edges  of  the  wound  are  to  be  closed  by  superficial  sutures 
of  the  sam.e  material. 

Superficial  wounds  are  closed  by  adhesive  plaster  or  collodion 
dressings. 

Drainage. — In  all  deep  wounds  drainage  must  he  provided  for,  as 
the  exuded  serum  is  usually  considerable  in  amount,  and  if  it  has  no 
way  of  escape,  produces  tension  and  pain,  and  ofifers  a  fertile  soil  for 
the  growth  of  micro-organisms. 

Drainage  is  secured  by  sterilized  rubber  tubing,  decalcified 
chicken-bone,  glass  tubes,  strands  of  catgut,  silk,  horse-hair,  or  strips 
of  gauze. 

Drainage-tubes  are  rarely  ever  necessary  in  the  region  of  the  face. 
The  use  of  drainage-tubes  increases  the  liability  to  the  formation  of 
scars,  hence  they  should  be  dispensed  with  as  far  as  possible  in  opera- 
tions upon  the  face.  In  capital  operations,  traumatic  wounds,  and 
operative  wounds  involving  the  antrum  of  Highmore,  drainage-tubes 
often  become  necessary. 

Physiological  Rest. — Rest  of  the  injured  part,  and  of  the  entire 
body,  is  imperatively  demanded  in  the  treatment  of  all  serious  wounds, 
and  is  of  great  value  in  all  classes  of  wounds. 

Rest  in  great  measure  prevents  inflammation,  as  taught  by  Hilton. 


172  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

The  position  of  the  injured  part  should  be  such  as  to  favor  a 
normal  blood-supply,  while  immobility  adds  greatly  to  the  rapidity  of 
the  healing  process. 

Wounds  in  parts  which  on  account  of  their  particular  function  it 
is  difficult  to  keep  at  perfect  physiological  rest, — like  surgical  wounds 
of  the  lip,  following  operations  for  hare-lip  and  cleft  palate  in  nursing 
infants, — do  not  always  give  as  perfect  results  as  do  wounds  in  other 
locations  that  can  be  controlled.  Anything  like  perfect  rest  of  the  lips 
or  palate  in  such  children  is  an  impossibility;  feeding  and  crying  are 
among  the  principal  occupations  of  the  normal  baby  when  not  asleep. 
The  motions  incident  to  these  functions  more  or  less  disturb  the 
process  of  healing,  and  as  a  consequence  the  best  results  are  not  always 
obtainable. 

Dressings. — The  character  of  the  dressings  and  their  adjustment 
are  matters  of  considerable  consequence  in  the  healing  of  wounds.  In 
these  days  of  antiseptic  surgery,  no  intelligent  surgeon  would  think  of 
using  other  than  aseptic  dressings. 

The  main  objects  of  dressings  are,  to  support  the  wounded  tissues 
during  the  process  of  healing,  to  absorb  the  discharges,  and  to  prevent 
the  ingress  of  all  substances  to  the  injured  tissues  which  cause  or  favor 
septic  infection.  Antiseptic  dressings,  like  the  plug  of  cotton  inserted 
into  the  mouth  of  the  test-tube  filled  with  sterilized  bouillon,  obstruct 
the  entrance  of  the  septic  micro-organisms  found  in  the  dust  and 
atmosphere  almost  everywhere,  and  thus  prevent  the  establishment  of 
putrefactive  fermentation. 

Wounds,  like  the  unprotected  bouillon  when  exposed  to  the 
atmosphere,  soon  become  the  seat  of  colonies  of  septic  bacteria.  If 
the  resistance  of  the  tissues  is  impaired,  or  the  environment  of  the 
wound  is  such  as  to  favor  their  rapid  development,  the  tissues  are  soon 
overwhelmed,  the  reparative  process  is  impeded  or  entirely  suspended, 
the  leucocytes  and  embryonal  cells  lose  their  vitality,  and  suppuration 
is  the  result;  while,  on  the  other  hand,  these  conditions  do  not  obtain 
if  the  wound  has  been  dressed  according  to  the  best  aseptic  methods. 

The  adjustment  of  the  dressings  must  always  be  governed  by  the 
extent,  location,  character,  surroundings,  and  seriousness  of  the 
wound.  Thicker  dressings  are  required  in  cases  with  copious  dis- 
charges than  in  those  with  little  or  no  discharge.  The  covering,  how- 
ever, should  always  be  sufficiently  thick  to  protect  the  wound  from 
infection  from  the  outside. 

In  applying  the  dressings,  care  must  be  exercised  not  to  produce 
uncomfortable  pressure,  as  this  soon  becomes  painful,  and  may  estab- 
lish inflammatory  symptoms  from  mechanical  irritation,  and  thus 
jeopardize  the  healing  of  the  wound. 

In  operations  upon  the  lips  and  face  impervious  dressings  are  the 
best;  the  collodion  dressing  has  the  preference. 


CHAPTER   XIX. 
GUNSHOT  WOUNDS. 

Under  the  term  Gunshot  are  included  all  those  wounds  which  are 
caused  by  projectiles  that  have  been  propelled  by  the  elastic  or  ex- 
plosive power  of  gunpowder,  dynamite,  nitro-glycerin,  etc.  To  the 
injuries  inflicted  by  these  missiles  may  be  added  the  wounds  caused 
through  the  concussions  of  the  explosives  themselves  by  fragments  of 
wood,  iron,  or  stone,  by  portions  of  the  body  of  a  comrade, — pieces  of 
bone  or  teeth, — or  portions  of  accoutrements  or  clothing.  The  pro- 
jectiles used  by  civilized  nations  in  modern  warfare  are  buckshot; 
bullets,  round  and  conical;  shrapnel,  grape  and  canister,  chain  or  bar- 
shot;  solid  cannon-balls,  shells,  slugs,  explosive  musket-balls,  hand- 
grenades,  and  torpedoes. 

These  missiles  are  projected  with  great  velocity  and  force.  The 
wounds,  therefore,  which  are  inflicted  by  them  are  classed  as  con- 
tusions, lacerations,  penetrations,  perforations^  simple  fractures,  partial 
fractures,  complete  fractures,  with  various  degrees  of  comminution 
and  destruction  of  substance. 

The  great  majority  of  gunshot  wounds  are  produced  by  the  ball 
or  bullet,  either  the  round  or  conical.  At  the  commencement  of  the 
War  of  the  Rebellion,  both  opposing  armies  were  obliged  to  employ 
the  round  ball  to  a  greater  or  less  extent,  on  account  of  the  construc- 
tion of  the  firearms.  Later,  through  the  introduction  of  the  rifle  arm, 
the  conical  bullet  superseded  the  round  ball.  The  rifled  arms  most 
commonly  used  were  the  Enfield,  the  Austrian,  and  the  Springfield. 
The  Enfield  carried  a  shot  weighing  450  grains;  the  Austrian,  one 
weighing  460  grains,  and  the  Springfield,  one  of  500  grains. 

Hamilton  says,  "Some  idea  of  the  velocity  and  power  of  the 
conical  shot  can  be  obtained  from  the  following  statement:  When  fired 
from  a  Springfield  rifle,  with  a  charge  of  60  grains  of  powder,  at  200 
yards,  it  will  penetrate  eleven  one-inch  pine  planks,  separated  by  inter- 
vals of  one  and  one-half  inches;  while  at  a  distance  of  1000  yards  it 
will  penetrate  one  such  plank,  and  enter  the  second  to  the  depth  of  one- 
quarter  of  an  inch." 

The  preponderance  of  gunshot  injuries  over  other  wounds  during 

173 


174  SURGERY    OF    THE    FACE,    MOUTH,    AND   JAWS. 

the  Civil  War  is  shown  by  the  report  of  the  Surgeon-General  of  the 
army.  There  were  treated  in  hospitals  during  that  period  246,712 
cases  of  wounds  caused  by  weapons  of  war.  Of  these,  245,790  were 
gunshot  wounds  and  992  were  bayonet  and  sabre  wounds.  And  from 
the  same  report  it  is  found  that  by  far  the  greater  number  of  gunshot 
injuries  were  inflicted  by  projectiles  from  small  arms,  the  rifle  or  pistol. 

The  number  of  cases  in  which  the  nature  of  the  missiles  was  with 
certainty  ascertained  was  141,961.  Of  these,  127,929,  or  90.1  per  cent., 
were  caused  by  shot  from  small  arms. 

Among  the  casualties  of  the  War  of  the  Rebellion  there  were  re- 
corded as  occurring  from  explosive  bullets  130  cases  of  wounds.  In- 
juries from  this  form  of  projectile  are  much  more  serious  than  from  the 
ordinary  round  or  conical  bullet.  The  destruction  of  the  soft  parts  is 
greater,  the  bony  parts  are  more  extensively  shattered,  hemorrhage,  both 
primary  and  secondary,  is  much  more  common,  sloughing  of  an  ex- 
tensive character  is  more  likely  to  occur,  and  the  process  of  repair  is 
slow  and  unsatisfactory. 

Diagnosis. — Small  fragments  of  exploded  shell,  case  and  canister 
shot,  produce  effects  which  do  not  materially  differ  from  the  injuries 
caused  by  missiles  from  small  arms. 

Large  fragments  of  shell  produce  great  laceration  and  destruction 
of  tissues.  When  of  sufficient  size  and  velocity,  they  may  carry  away 
a  portion  of  the  trunk,  or  an  extremity.  Under  such  circumstances 
the  laceration  and  contusion  may  be  very  great. 

Wounds  made  by  conical  bullets  are  frequently  of  irregular  shape 
at  the  points  of  entrance  and  exit.  Sometimes  the  entrance  is  indicated 
by  a  mere  slit,  or  it  may  be  irregularly  round  or  oval,  or  broadly  lacer- 
ated; while  the  wound  of  exit  is  always  larger  and  still  more  irregular. 
The  track  of  the  wound  also  gradually  increases  in  size  as  it  reaches 
the  point  of  exit,  thus  giving  it  a  somewhat  conical  form. 

Wounds  caused  by  round  balls  are  quite  generally  round,  the 
wound  not  larger  than  the  missile;  the  surface  depressed  at  the  point 
of  entrance,  and  the  edges  discolored.  The  wound  of  exit  is  irregu- 
larly round,  and  somewhat  larger,  while  the  surface  is  elevated  and  the 
edges  everted.  The  round  bah  is  not  so  destructive  to  tissue  as  the 
conical  shot,  which,  on  account  of  its  increased  weight  and  velocity, 
meets  with  little  resistance  from  any  of  the  structures  of  the  body  at 
ordinary  range,  and  is  seldom  deflected  from  a  straight  line,  crushing, 
tearing,  and  comminuting  everything  in  its  path.  The  wounds  of  en- 
trance ajtid  exit  will  correspond  in  most  cases  with  the  line  of  projec- 
tion. Hamilton  mentions  a  peculiar  exception  to  this  rule,  to  be  found 
in  the  Army  Medical  Museum  at  Washington:  "A  conical  ball,  marked 
4622,  entered  the  thoracic  parietes  on  one  side,  made  a  semi-circuit  of 
the  body,  and  emerged  at  a  point  corresponding  to  the  place  of  en- 
trance on  the  opposite  side." 


GUNSHOT    WOUNDS.  175 

Round  balls,  from  their  shape  and  decreased  velocity,  are  more 
liable  to  be  deflected  from  the  line  of  projection  at  the  point  of  contact 
with  the  surface  of  the  body,  or  of  their  passage  through  the  various 
tissues. 

Leaden  bullets,  when  they  come  in  contact  with  bony  tissue,  often 
become  deformed  or  split  into  fragments,  the  pieces  tearing  through  the 
tissues  at  a  tangent  from  the  line  of  projection,  causing  several  wounds 
of  exit.  When  the  momentum  is  sufficient  to  cause  penetration  of  bony 
tissue,  it  is  usually  badlv  comminuted  or  more  or  less  splintered. 

Experiments  made  with  steel- jacketed  bullets  by  the  Army  Medical 
Department  and  exhibited  at  the  World's  Fair  at  Chicago,  in  1893, 
proved  conclusively  that  projectiles  made  of  metal  which  retained  its 
form,  in  passing  through  the  epiphyses  of  long  bones  or  other  spongy 
bone,  would  in  a  majority  of  cases,  under  their  full  momentum,  pene- 
trate without  fracture,  and  rarely  fissure  or  comminute  this  tissue. 
When  passing  through  the  shaft  of  these  bones  fracture  was  the  usual 
result,  but  with  less  comminution  and  splintering. 

In  the  Report  of  the  Surgeon-General,  U.  S.  Army,  1893,  atten- 
tion is  called  to  a  series  of  experiments  conducted  at  Frankford  Ar- 
senal, Pa.,  by  Capt.  L.  A.  LaGarde,  in  connection  with  the  Ordnance 
Department  of  the  Army : 

"The  weapons  used  in  the  experiments  were  the  Springfield  rifle, 
caliber  0.45,  and  an  experimental  Springfield,  caliber  0.30;  the  former 
giving  an  initial  velocity  of  1301  feet  per  second  to  500  grains  of  com- 
pressed lead  of  cylindro-conoidal  form,  cannelured  and  lubricated;  the 
latter  impressing  a  velocity  of  2000  feet  per  second  on  a  bullet  weighing 
220  grains,  and  consisting  of  lead  incased  in  a  jacket  of  German  silver. 
The  penetration  of  the  latter  was  found  to  be  greater  than  that  of  the 
old  arm  and  bullet  at  all  ranges,  and  the  amount  of  shock  correspond- 
ingly less.    Explosive  effects  at  short  ranges  differed  but  little  for  the 
two  projectiles,  but  the  explosive  zone  of  the  smaller  bullet  extended  to 
350  yards,  or  100  yards  farther  than  the  other.    Beyond  the  limits  of 
the  explosive  zone  the  destructive  effects  of  the  smaller  bullet  became 
less  than  those  of  the  larger,  and  this  difference  was  especially  notice- 
able from  the  500  to  the  1500  yard  ranges,  and  in  the  wounds  inflicted 
on  the  joints  and  soft  parts.    The  lessened  severity  of  wounds  at  these 
ranges  is  attributed  in  part  to  the  small  amount  of  flattening  or  other 
deformation  found  in  the  jacketed  bullet  after  impact  even  with  bone. 
At  longer  ranges,  where  velocity  became  lessened,  the  small  bullet 
again  produced  extensive  comminution  of  bones  and  disorganization 
of  soft  parts,  attributed  to  a  sideways  impingement.     Dr.  LaGarde's 
experiments  show  that  the  heat  imparted  to  a  projectile  by  fhe  ignition 
of  the  powder,  the  resistance  in  the  barrel,  etc.,  has  been  much  ex- 
aggerated.      It    is    certainly    insufficient    to    render    a    bullet    aseptic. 


176  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

Lesions  in  wounds  cannot  be  attributed  in  any  way  to  the  heat  im- 
parted by  the  bullet,  but  they  may  be  caused  by  septic  infection  before 
firing.  Of  the  jacketed  missiles  the  cupro-nickeled  steel  bullet  is  cer- 
tainly the  best,  as  its  mantle  does  not  part  from  its  nucleus  on  impact 
with  bone.  As  its  penetration  is  not  lessened  by  deformation  its  mili- 
tary efficiency  is  greater  than  that  of  other  missiles;  and  while  it  is 
capable  of  disabling  more  men  than  a  bullet  which  becomes  impaired  in 
form,  the  wounds  occasioned  by  it  are  less  destructive  to  the  individual." 

Dr.  LaGarde  says,  in  speaking  of  explosive  effects:  one  should  not 
confound  the  term  explosive  effects  with  explosive  action.  The  latter 
term  should  be  restricted  to  those  wounds  caused  by  an  explosive 
bullet — ^that  is,  a  projectile  that  explodes  on  impact.  Such  a  projectile 
is  hollow,  charged  with  explosive  materials  which  ignite  when  the  bullet 
strikes  against  a  hard  substance,  like  bone.  The  bullet  is  thus  torn 
asunder,  causing  usually  an  extensive  lacerated  wound.  On  the  other 
hand  the  projectiles  possessed  of  superior  velocities  do  not  explode  on 
impact.  They  are  solid,  and  at  most  seldom  become  altered  in  shape. 
Indeed,  those  of  the  small  caliber,  inclosed  in  a  mantle  of  the  hardest 
steel,  do  not  even  deform  when  they  collide  with  the  most  resistant 
parts  of  the  human  body ;  and  yet  they  are  proverbial  for  their  explosive 
effects  in  the  proximal  ranges. 

Explosive  effects  are  well  exhibited  by  firing  the  projectile  of  the 
old  and  new  arm  mto  tin  cans  at  close  range.  For  the  purpose  of  com- 
parison, if  the  experiment  is  done  by  firing  into  tins  when  empty,  and 
into  another  set  of  tins  of  similar  capacity  filled  with  water,  the  empty 
cans  will  exhibit  no  alteration  in  shape.  The  orifice  of  entrance  and 
exit  of  the  bullet  will  correspond  in  size  to  the  sectional  area  of  the 
projectile;  on  the  other  hand  the  tins  that  were  filled  with  water  will 
show  great  alteration  in  shape.  The  sides  of  the  vessels  will  exhibit  a 
bulging  as  if  some  interior  force  had  exerted  an  outward  pressure  in  all 
directions.  The  orifice  of  entrance  will  usually  correspond  to  the  caliber 
of  the  projectile,  while  the  orifice  of  exit  will  be  marked  by  a  large 
irregular  opening  with  everted  edges. 

If  the  experiments  are  continued  upon  a  cadaver  at  close  range, 
impact  with  a  resistant  bone  will  present  certain  characteristic  features : 
The  wound  of  entrance  in  the  skin  will  correspond  in  size  to  the 
diameter  of  the  bullet ;  the  wound  of  exit  will  be  marked  by  a  bursting 
forth  of  the  skin.  "The  track  leading  to  the  bone  is  conical  in  shape, 
the  base  of  the  cone  corresponds  to  the  wound  of  exit  in  the  skin,  and 
the  apex  of  the  cone  corresponds  to  the  seat  of  fracture.  The  bone  is 
finely  comminuted.  A  close  inspection  shows  that  the  bony  particles 
have  been  driven  into  the  tissues  at  right  angles  to  the  bullet  track; 
while  it  is  not  uncommon  to  find  bony  sand  in  the  wound  of  entrance." 

"Five  theories  have  been  advanced  to  explain  these  explosive  effects  : 


GUNSHOT    WOUNDS.  177 

Hydraulic  pressure. 
Compressed  air,  or  the  projectile  air. 
Rotation  of  the  bullet. 
Deformation  of  the  bullet. 
Heating-  of  the  bullet. 

1.  Hydraulic  Pressure. — "'The  term  'hydraulic  theory'  has  been 
employed  by  many  writers  to  explain  the  highly  destructive  effects 
often  found  in  gunshot  wounds  at  the  proximal  ranges.  It  is  based  on 
the  principle  of  Pascal.  This  principle  is  only  applicable  to  a  closed 
vessel  filled  with  liquid.  In  accordance  with  this  principle  if  a  certain 
pressure  is  made  upon  a  given  area  of  the  imprisoned  liquid  a  similar 
pressure  w-ill  be  exerted  within  on  like  areas  of  the  vessel  walls." 

The  experiments  of  Coler,  Stephenson,  and  others  have  effectually 
disproved  this  so-called  hydraulic  theory.  They  have  show'n  that  the 
highly  destructive  eft"ects  noted  bv  firing  into  sealed  vessels  filled  with 
liquid  w^ere  to  be  noted  in  the  same  way  when  the  vessels  were  unsealed. 
Ordinary  tin  buckets  filled  with  water,  w^hether  the  tops  w^ere  in  place 
or  not,  sustained  the  same  amount  of  destruction. 

2.  Compressed  Air,  or  Projectile  Air. — This  is  called  the  projectile 
air  of  ]\Ielsens,  because  it  is  he  who  recently  revived  this  theory  of 
projectile  air  in  explanation  of  the  destruction  in  w'ounds  that  so  often 
suggests  explosive  action.  Boys  has  succeeded  in  making  exact  photo- 
graphs of  bullets  in  transit.  He  caused  the  bullet  to  cross  an  electric 
circuit.  At  the  moment  of  contact  wnth  the  circuit  the  bullet  and  the 
immediate  vicinity  of  its  trajectory  are  illumined  by  a  spark  which 
serves  to  throw'  the  image  upon  a  photographic  plate,  A  study  of  the 
views  thus  obtained  distinctly  shows  a  pad  of  compressed  air  in  front 
of  the  projectile.  ]\Ielsens  believed  that  this  cushion  of  air  entered  the 
tissues  at  the  moment  the  skin  was  penetrated  or  before,  and  that  the 
destruction  of  tissues  w'as  to  be  accounted  for  by  the  explosion  which 
occurred  when  the  compressed  air  again  regained  its  normal  volume. 
The  tissues  fail  to  show-  any  evidence  of  air  having  been  forced  into 
them,  such  as  one  might  infer  from  the  presence  of  emphysema,  and 
altogether  it  may  be  said  that  the  theory  of  projectile  air  has  but  little 
to  recommend  it  to  consideration. 

3.  Rotation  of  the  Bullet. — The  rotation  of  a  rifle  bullet  is  im- 
parted to  it  by  the  twist  in  the  barrel.  The  longer  the  bullet  the  sharper 
must  be  the  twist.  The  old  Springfield  0.45-caliber  bullet,  which  was 
but  tw-o  calibers  in  length,  and  which  revolved  800  turns  per  minute  at 
the  muzzle,  described  one  complete  turn  in  22  inches,  because  the  twist 
in  the  barrel  corresponded  to  one  complete  turn  in  22  inches.  In  the 
present  rifle  the  twist  is  sharper,  viz,  one  turn  in  about  10  inches,  and 
the  rate  of  revolution  is  estimated  at  2400  turns  per  minute.  It  is 
generallv  admitted  by  ballisticians  that  the  velocity  of  rotation  is  well 

13 


17^^  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

maintained, — that  it  does  not  diminish  with  the  velocity  of  translation. 
Taking  for  granted  that  the  projectile  makes  a  complete  turn  in  ten 
inches,  we  must  admit  that  the  rotation  of  the  bullet  can  have  but  a 
minimum  amount  of  effect  to  display  in  traversing  a  thigh  bone  which 
may  be  but  one  inch  in  diameter,  because  in  traversing  it  the  ball  is 
making  only  one-tenth  of  a  turn. 

4.  Deformation. — The  fact  that  the  old  leaden  bullet  became  de- 
formed when  colliding  with  a  resistant  bone,  especially  at  short  range, 
added  greatly  to  the  amount  of  destructive  effects.  Deformation  can 
find  no  plea  as  a  cause  of  destructive  effect  in  all  cases  since  the  steel- 
clad  bullet  that  does  not  deform  is  proverbial  for  the  creation  of  ex- 
plosive effects. 

5.  Heating. — Heating  of  the  bullet  by  the  act  of  ignition  to  ex- 
plain explosive  effects  found  adherents  long  ago,  and  it  was  not  until 
recent  years  that  this  erroneous  notion  was  set  aside.  We  were  able  to 
show  in  1892  that  the  heat  on  a  bullet  caused  by  the  ignition  of  the 
powder  is  not  sufficient  to  destroy  the  ordinary  septic  germs.  The  ex- 
periments were  conducted  with  missiles  from  low-velocity  rifles  and  the 
weapons  of  reduced  caliber  with  the  same  result.  To  speak  briefly,  we 
can  truthfully  say  that  the  heat  of  a  missile  cuts  no  figure  in  gunshot 
wounds. 

The  true  cause  of  explosive  effects  is  the  superior  energy  possessed 
by  the  bullet  at  the  moment  of  impact.  The  bone,  and  even  the  soft 
parts,  receive  a  large  amount  of  this  energy  and  move  "outwards  in 
lines  radiating  from  the  long  axis  of  the  bullet-track  with  such  a  degree 
of  force  that  they  act  as  secondary  missiles  on  the  neighboring  tissues 
and  cause  still  further  smashing  and  pulping  of  the  tissues.  Even 
fluid  particles  participate  in  this  secondary  action,  but  it  is  all  the  more 
marked  when  fragments  of  bone  are  driven  apart  in  this  manner." 
(Stephenson.) 

The  wound  of  exit  of  the  small-caliber  bullet  was  generally  larger 
than  the  wound  of  entrance,  and  beyond  the  zone  of  explosive  effects 
especially  it  was  generally  round,  marked  at  times  by  a  mere  slit ;  again 
it  was  star-shaped,  T-shaped,  semicircular,  etc. ;  the  edges  were  gen- 
erally turned  out. 

Upon  the  whole,  the  gunshot  injuries  by  the  Mauser,  the  reduced- 
caliber  rifle  of  the  Spaniards,  were  in  keeping  wath  those  humane 
effects  so  confidently  predicted  by  experimenters  generally.  The 
wounds  of  soft  parts  healed  without  suppuration.  The  lesions  of  bone 
that  formerly  caused  such  a  high  mortality  in  the  statistics  of  wars  were 
most  successfully  treated  by  antiseptic  dressings  and  the  proper  use  of 
immobilizmg  materials.  Comminution  and  fissuring  were  noticed  in 
the  diaphyses.  It  was,  however,  seldom  necessary  to  cut  down  for  the 
purpose  of  removing  spiculse  of  bone,  as  the  displacement  of  fragments 


GUNSHOT    WOUNDS.  179 

(lid  not  rctiuirc  this  amount  oi  interference.  The  clean-cut  perforations 
of  the  epiphyses,  without  fracture,  rendered  joint  injuries  the  most 
favorable  of  all  bone  lesions  for  rapid  healinf^,  with  little  or  no  loss  of 
function.    This  was  especially  true  of  gunshots  of  the  knee. 

The  English  in  the  Soudan,  and  in  the  Ashantee  campaign,  were  so 
doubtful  of  the  efficacy  of  this  small-caliber  missile  to  arrest  the  impetus 
of  savage  tribes  that  they  resorted  to  the  practice  of  making  their  ■ 
missile  explosive  by  tiling  the  nose  through  the  steel  casing  enough  to 
expose  the  lead  core.  This  is  the  famous  Dum-Dum  bullet,  which  takes 
Its  name  from  the  place  of  its  manufacture  in  India.  When  the  lead  is 
exposed,  as  stated,  the  projectile  disintegrates  on  impact  with  a  resistant 
structure.  The  fragments  of  the  steel  mantle  and  lead  core  acting  as 
individual  missiles,  add  greatly  to  the  destructive  effects  in  the  foyer 
of  fracture. 

Among  the  general  conclusions  of  the  report  of  these  "Experi- 
ments with  Projectiles  of  Hard  Exterior"  are  the  following: 

"The  differences  between  the  effects  of  the  bullets  of  hard  exterior 
and  the  leaden  projectiles  lie  in  the  greater  penetration  of  the  first,  and 
this  in  turn  is  due  to  greater  velocity,  diminished  frontage,  and  the 
hard  envelope  which  diminishes  the  chances  of  deformation. 

"For  the  two  bullets,  especially  when  a  resistant  bone  is  struck,  the 
amount  of  lesion  is  in  proportion  to  the  velocity. 

"The  shock  impressed  upon  a  member  increases  with  the  velocity, 
whether  a  bone  is  traversed  or  not.  It  is,  however,  always  greater  with 
the  leaden  projectiles. 

"The  explosive  effects  at  very  short  range  are  about  the  same  for 
the  two  projectiles.  They  continue,  however,  up  to  350  yards  wdth  the 
smaller  projectiles  and  cease  at  about  200  yards  with  the  leaden  pro- 
jectiles. 

"The  smaller  frontage  of  the  hard  mantle  projectiles  causes  them 
to  inflict  injuries  something  after  the  manner  of  a  subcutaneous  wound, 
when  the  soft  parts  alone  are  traversed,  and  the  small  wounds  of 
entrance  and  exit  and  the  narrow  track  of  the  missiles  are  favorable 
circumstances  to  a  rapid  healing. 

"A  wound  of  exit  the  diameter  of  a  finger  or  thumb  in  area  in- 
dicates for  either  bullet  fracture  of  bone  with  splintering,  and  in  accord- 
ance with  the  observations  of  Delorme  and  Nimier,  who  experimented 
with  the  projectile  of  the  Gras  as  compared  with  the  effects  of  the 
Lebel  projectile,  tears  of  similar  extent  in  the  clothing  are  alike  in- 
dicative. 

"Injuries  inflicted  outside  the  zone  of  explosive  effects  upon  the 
diaphyses  of  long  bones  always  show  less  comminution  with'  the  small 
bullets  of  hard  exterior.  The  fissures  are  often  subperiosteal  and  the 
fragments  are  larger. 


l8o  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

"Beyond  the  zone  of  explosive  effects  the  projectiles  of  hard  ex- 
terior almost  invariably  perforate  or  clutter  the  joint  ends  of  bones,  and 
the  lesions  of  the  articulations  are  never  so  grave. 

"The  projectiles  of  hard  exterior  lodge  more  rarely  in  the  tissues 
than  the  leaden  bullets.  The  latter  more  often  leave  fragments  of  lead 
in  the  foyer  of  fracture. 

"The  projectiles  of  hard  exterior  are  more  humane  than  the  old. 
Resections  and  amputations  will  not  be  so  often  required  hereafter. 
Soldiers  will  be  more  often  restored  to  the  state  useful  members  of  the 
community  instead  of  cripples  and  pensioners,  and  in  point  of  economy 
the  new  projectiles  confer  a  great  advantage. 

"As  the  projectiles  of  smaller  caliber  with  hard  mantles  are  less  apt 
to  lodge  or  to  carry  foreign  substances  into  the  wounds,  we  will  expect 
to  find  fewer  cases  of  suffering  due  to  the  remote  effects  of  unextracted 
foreign  bodies.  This,  w'e  should  bear  in  mind,  is  one  of  the  most  fre- 
quent sources  of  protracted  suff'ering  after  gunshot  wounds. 

"The  frontage  of  the  new  armament  bullets  being  much  less,  and 
the  fact  that  the  bullets  seldom  lodge,  will  contribute  to  increase  the 
percentage  of  recoveries  in  gunshot  wounds  of  the  lungs,  and  this  will 
be  especially  true  in  the  wounds  of  this  class  which  may  be  inflicted 
beyond  the  zone  of  explosive  effects. 

"When  the  new  bullets  do  become  lodged  they  w'ill  be  less  apt  to 
cause  irritation,  for  two  reasons — they  are  lighter  in  weight  and  seldom 
deform."  [Fig.  62  shows  a  Roentgen-ray  picture  of  a  Mauser  bullet 
lodged  in  the  neck  of  a  returned  soldier  from  the  War  m  the  Philippines 
(taken  from  the  collection  of  the  U.  S.  Army  General  Hospital, 
Presidio  of  San  Francisco).] 

"Wounds  of  the  face  from  the  new  projectiles  will  cause  less  dis- 
figurement. 

"Fatal  Primary  Hemorrhage  in  the  Field. — There  are  no  statistics 
bearing  on  the  percentage  of  cases  of  fatal  primary  hemorrhage  in 
battle,  because,  as  a  rule,  the  surgeons  are  so  busy  in  caring  for  the 
wounded  that  there  is  no  time  to  devote  to  the  dead,  but  it  is  generally 
admitted  that  the  number  of  cases  of  fatal  primary  hemorrhage  is  large. 
When  the  leaden  projectile  encounters  resistant  bone,  pieces  of  lead  are 
nearly  always  detached  at  the  moment  of  impact.  If  the  momentum  of 
the  projectile  is  still  sufficient  the  pieces  of  lead  and  splinters  of  bone 
act  as  secondary  projectiles,  and  the  danger  of  w^ounding  neighboring 
vessels  is  consequently  increased.  Since  the  new  projectiles,  outside  the 
zone  of  explosive  eft'ects  especially,  cause  less  shattering,  and  as  they 
seldom  deform,  the  amount  of  danger  to  blood-vessels  will  not  be  so 
great,  hence  the  cases  of  fatal  primary  hemorrhage  in  future  battles  will 
be  less." 

The  report  of  the  Surgeon-General,  U.  S.  Army,  for  1900,  in  re- 


GUNSHOT    WOUNDS. 


l8l 


ferring  to  the  gunshot  wounds  of  the  late  war  with  Spain   (  iSyS  and 
1899),  says: 

"Of  the  4919  men  injured  by  gunshot  during  the  years  1898  and 
1899,  586  were  killed  and  4333  were  wounded  and  received  into  the  field 
and  other  hospitals.  The  killed  constituted  11.9  per  cent,  of  those 
struck,  the  wounded  88.1  per  cent.  In  other  words,  i  man  was  killed 
for  every  7.4  wounded.      The  ^lauscr  bullet  must  therefore  be  regarded 

Fig.  62. 


Mauser  Bullet  lodged  in  the  Tissues  of  the  Neck. 

as  less  deadly  than  the  larger  missile  used  during  the  Civil  War.     The 
Medical  and  Surgical  Historv  of  the  Civil  War  shows  the  following 

casualties : 

Killed.  Wounded. 

United  States  troops 59-86o  280,040 

Confederate   troops   51425  '227.871 

Total    111,285  507.911 


l82  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

"In  percentages  the  casualties  were  :  Killed,  17.97 ;  wounded,  82.03  ; 
or  one  man  killed  to  every  4.56  wounded.  The  relative  proportion  of 
killed  was  therefore  considerably  larger  during  the  Civil  War  than  dur- 
ing our  recent  experiences.  It  is  to  be  noted,  also,  that  many  of  the 
wounds  of  the  past  two  years  were  made  by  missiles  of  large  caliber. 
Of  those  reported  in  1899,  471  were  specially  stated  as  having  been 
caused  by  the  Remington  bullet  of  caliber  0.45.  It  is  safe  to  say  that 
had  the  whole  number  of  wounds  received  been  inflicted  by  the  smaller 
Mauser  or  Krag-Jorgensen  bullet  the  percentage  of  immediately  fatal 
wounds  would  have  been  materially  lessened. 

"The  less  deadly  character  of  the  injuries  inflicted  by  the  modern 
bullet  is  manifested,  also,  when  we  exclude  the  killed  and  regard  only 
those  wounds  which  came  under  the  care  of  the  surgeons.  Of  these, 
during  the  two  years,  there  were  4333,  and  259  of  the  patients,  or  6  per 
cent,  of  the  whole  number,  died.  The  corresponding  percentage  from 
the  records  of  the  Civil  War  was  14.3.  The  Medical  and  Surgical  His- 
tory of  the  War  of  the  Rebellion  shows  that  among  the  white  troops  of 
the  Army  there  were  borne  on  the  reports  of  sick  and  wounded  230,018 
gunshot  wounds,  of  which  32,907,  or  14.3  per  cent.,  proved  fatal.  The 
marked  reduction  of  the  ratio  of  killed  to  wounded  may  be  placed  to  the 
credit  of  the  small  caliber  bullet ;  but  the  lessened  mortality  among  the 
cases  which  came  into  hospital  may  not  wholly  be  attributed  to  the 
humane  character  of  the  wounds  inflicted  by  the  missile.  Due  credit 
must  be  given  to  the  improved  surgical  methods  of  the  present  day. 
Wounds  of  any  region  of  the  body  may  be  taken  in  comparison  and  the 
result  will  always  be  found  to  show  a  decided  lessening  in  the  percent- 
age of  cases  ending  fatally  among  those  of  the  past  two  years  as  com- 
pared with  those  of  the  Civil  War 

"Not  only  limbs  but  lives  were  saved  by  the  surgical  practice  of  the 
past  two  years.  In  the  82  gunshot  fractures  of  the  femur  the  upper 
third  was  involved  in  32,  of  which  5  were  fatal ;  the  middle  third  in  27, 
of  which  3  were  fatal ;  and  the  lower  third  in  2^,  of  which  i  was  fatal. 
The  mortality  varied  from  4.3  per  cent,  of  the  cases  in  which  the  lower 
third  was  fractured  to  15.6  per  cent,  of  the  cases  in  which  the  upper 
third  was  the  site  of  the  injury,  whereas  the  corresponding  percentages 
of  fatal  cases  during  the  Civil  War  were,  respectively,  42.8  and  49.7. 
The  whole  of  the  lessened  mortality  in  these  serious  fractures  may  be 
credited  to  the  protection  given  to  the  wound  by  the  first-aid  dressing 
and  to  the  care  exercised  in  the  subsequent  aseptic  treatment  of  the 
fractured  limb. 

"In  penetrating  wounds  of  the  thorax  the  rate  of  mortality  fell 
from  62.6  per  cent,  during  the  Civil  War  to  27.8  per  cent,  during  the 
years  1898  and  1899.  The  Civil  War  reports  show  8403  cases  in  which 
the  results  were  determined ;  5260  deaths  occurred  among  the  number. 


GUNSHOT    WOUNDS.  183 

The  reports  for  the  later  years,  as  already  stated,  show  198  cases,  of 
which  only  55  were  fatal. 

"There  were  durin.e-  the  Civil  War  3475  penetrating  wounds  of  the 
abdomen  in  which  the  ultimate  results  were  determined;  3031  of  these, 
or  ^j.2  per  cent,  of  the  total,  proved  fatal.  During  the  years  1898  and 
1899  116  cases — 81  fatal — were  recorded,  the  fatal  cases  constituting  70 
per  cent,  of  the  total.  Of  10  cases  in  which  laparotomy  w^as  performed, 
9  were  fatal. 

"The  alteration  in  the  percentages  of  mortality  in  fractures  of  the 
cranium  is  less  marked  than  in  wounds  of  other  parts  of  the  body.  Of 
4243  cases  of  cranial  fracture  during  the  Civil  War  2514,  or  59.2  per 
cent,  were  fatal.  In  1898  and  1899  68  cases  were  recorded,  with  37 
deaths,  the  latter  forming  54.4  per  cent,  of  the  whole  number." 


CHAPTER     XX. 

GUNSHOT  WOUNDS  OF  THE  FACE. 

Many  of  the  bones  of  the  face  are  so  thin  and  shell-hke,  and  the 
parts  so  exceedingly  vascular,  that  gunshot  injuries  with  the  leaden 
bullet  are  likely  to  cause  great  comminution  of  the  bones,  and  serious 
hemorrhage,  both  of  a  primary  and  secondary  nature. 

Laceration  of  the  soft  tissues,  with  hemorrhage  of  a  more  or  less 
serious  character,  is  a  constant  accompanying  feature  of  this  form  of 
gunshot  injuries  of  the  face,  while  the  mortality  is  exceedingly  high, 
both  from  the  immediate  effects  of  the  injury  and  from  secondary 
hemorrhage. 

According  to  the  report  of  the  Surgeon-General  of  the  Union 
Army,  the  principal  cause  of  fatalities  from  injuries  of  this  class  was 
secondary  hemorrhage,  and  this  seems  to  be  the  general  opinion  of  all 
surgeons  who  have  had  any  considerable  experience  in  military  sur- 
gery. 1 

The  fact  that  secondary  hemorrhage  is  so  common  in  gunshot 
injuries  of  the  face  is  explained  by  the  inaccessibility  of  the  vessels  to 
ligature,  while  ligation  of  the  carotid  does  not  always  prove  successful 
in  preventing  it  on  account  of  the  free  anastomosis  with  the  vessels  of 
the  opposite  side,  and  of  the  same  side. 

During  the  War  of  the  Rebellion,  there  were  reported  9416  gun- 
shot injuries  of  the  face.  Of  these,  4914  were  flesh  wounds,  with  3706 
recoveries,  58  deaths,  11 50  undetermined  results,  and  1.5  percentage 
of  fatalities.  The  remaining  4502  were  complicated  with  fractures  of 
the  bones;  3700  recovered;  404  died;  398  results  undetermined,  and 
percentage  of  fatalities,  9.8. 

The  mortality  is  always  very  much  higher  in  all  cases  of  gunshot 
injuries  complicated  with  fractures  of  the  bones.  The  effects  of  the 
injuries  from  the  rifled  firearm,  with  its  heavier  missile,  greater 
velocity,  and  surer  aim,  contrast  very  unfavorably,  from  this  stand- 
point, wdth  the  round  bullet  and  smooth-bore  musket. 

During  the  Crimean  War  there  were  533  wounds  of  the  face;  107 
were  complicated  with  bone  injury;  445  recovered,  and  reported  for 
duty;  74  were  invalided,  and  14  died;  percentage  of  fatality,  3.8. 

Wounds  of  the  face  from  gunshot  injuries  made  bv  the  leaden 


GUNSHOT    WOUNDS    OF    Tllli:    FACE.  Io5 

bullet  often  cause  great  distij^urenient  from  the  loss  of  tissue ;  but  as  a 
rule,  laving-  aside  the  fatalities  from  the  immediate  injury  and  s:condary 
hemorrhage,  thev  generall\-  do  well:  the  soft  tissues  heal  kindly,  and  it 
rarely  happens  that  there  is  an}-  extensive  necrosis  of  the  bones. 

Solid  shot  and  fragments  of  shell  striking  the  face  usually  prove 
fatal,  but  occasionally  an  individual  will  survive  after  having  a  consid- 
erable portion  of  the  face  carried  away.  Heath  mentions  some  very 
interesting  cases,  which  it  will  pay  the  student  who  is  specially  inter- 
ested in  such  matters  to  carefully  read. 

Quoting  again  from  the  report  of  the  Surgeon-General  U.  S. 
Army  for  1900 : 

"During  the  calendar  year  1898,  there  were  reported  from  the 
regular  Army  1457  gunshot  injuries.  1320  of  which  were  battle  casual- 
ties and  137  the  result  of  accidents,  quarrels,  attempted  suicide,  etc. 

"Of  the  battle  wounds,  1221  were  said  to  have  been  caused  by  bul- 
lets, 83  by  shell,  and  16  by  shrapnel.  In  57  cases  the  site  and  extent  of 
the  wounds  were  not  stated.  Flesh  wounds  in  various  parts  of  the  body 
numbered  860,  constituting  68.1  per  cent,  of  the  total  number  in  which 
the  site  of  the  wound  was  stated ;  85  were  penetrating  wounds  of  the 
thorax  or  abdomen ;  41  fractures  of  the  cranial  or  facial  bones,  and  7  of 
the  spine ;  140  fractures  of  the  upper  extremity,  in  86  of  which  only  the 
metacarpus  or  lingers  were  involved;  130  fractures  of  the  lower  ex- 
tremity, the  shaft  of  the  femur  being  involved  in  26.  the  knee  joint  in  17, 
the  leg  and  ankle  in  34,  and  the  metatarsus  and  toes  in  53. 

■'In  the  volunteer  force  during  the  calendar  year  1898,  689  gunshot 
injuries  were  reported.  Eighty-nine  of  these  were  immediately  fatal 
and  were  not  taken  up  on  the  reports  of  sick  and  wounded. 

"Of  the  600  cases  taken  on  sick  report,  29,  or  4.8  per  cent.,  ended 
fatally;  4  ended  in  death,  but  from  other  causes  than  the  gunshot  in- 
jury; 437  were  returned  to  duty;  18  were  discharged  on  certificates  of 
disability  in  1898,  and  8  others  in  1899 ;  7  were  discharged  by  order, 
and  the  injured  in  97  cases  were  mustered  out  with  their  regiments. 

''Of  the  600  cases,  362  were  battle  \vounds,  250  of  which  ended  in 
return  to  duty,  12  in  death  as  the  result  of  the  wounds,  and  4  in  death 
from  other  causes.  Six  of  the  wounded  men  were  discharged  on  certif- 
icates of  disability  in  1898  and  3  others  in  1899.  Three  were  dis- 
charged by  order  and  84  were  mustered  out  with  their  regiments. 

"Of  8  fractures  of  the  bones  of  the  cranium  4  terminated  fatally. 
Of  6  fractures  of  the  bones  of  the  face  i  proved  fatal  from  secondary 
hemorrhage  after  ligation  of  the  lingual  artery.  Of  13  wounds  of  the 
neck  3  were  fatal. 

"During  the  year  1899  there  were  reported  from  the  x\rmy,  regu- 
lars and  volunteers,  2276  cases  of  gunshot  injury,  with  149  deaths  or 
6.5  per  cent,  resulting  from  the  wounds,  and  4  deaths  from  causes  other 


lS6  SURGERY    OF    THE    FACE,    MOUTH,   AND    JAWS. 

than  the  wounds;  1714  were  returned  to  duty,  180  were  discharged  on 
certificates  of  disability,  134  by  order,  and  80  by  muster  out  or  expira- 
tion of  term  of  service,  while  15  remained  on  sick  report  at  the  date  of 
the  latest  reports. 

"In  addition  to  these  cases,  there  were  killed  by  gunshot  391  men 
whose  names  were  not  on  sick  report  at  the  time  of  their  death. 

"Of  the  2276  cases,  1759  were  wounds  received  in  action;  517  were 
not  battle  wounds,  but  411  of  them  were  received  in  the  line  of  duty. 
One  hundred  and  sixteen  of  the  battle  wounds,  or  6.6  per  cent.,  had  a 
fatal  ending,  and  136  terminated  in  discharge  for  disability. 

"Of  the  2276  gunshot  wounds  on  the  sick  reports  of  the  Army, 
regulars  and  volunteers,  in  1899,  ^^^  ^^^^  o^  injury  in  8  cases  is  not 
stated.  In  2268  cases  in  which  the  injured  part  is  specified,  the  head, 
face,  or  neck  was  w^ounded  in  257  cases,  or  11.4  per  cent. ;  the  upper  ex- 
tremity in  763  cases,  or  33.6  per  cent.,  and  the  lower  extremity  in  846 
cases,  or  37.3  per  cent.  But  if  the  369  cases  of  death  from  gunshot  in 
which  the  site  of  the  fatal  wound  is  specified  be  added  to  these  2268 
cases,  we  have  2637  cases  of  gunshot  injury,  of  which  431  injuries  of 
the  head,  face,  and  neck  constituted  16.4  per  cent,  of  the  total ;  590  of 
the  trunk,  22.4  per  cent. ;  763  of  the  upper  extremity,  28.9  per  cent.,  and 
853  of  the  lower  extremity,  32.3  per  cent. 

"But  a  more  accurate  view  of  the  relative  liability  of  various  parts 
of  the  body  to  gunshot  injury  may  be  obtained  if  to  the  gunshot  injuries 
received  in  1899  be  added  those  incurred  by  the  regular  and  volunteer 
troops  during  the  year  1898.  This  gives  a  total  of  4919  injuries,  845  of 
which  were  fatal.  The  aggregate  number  of  cases  in  which  the  location 
and  character  of  the  injury  were  stated  amounted  to  4756,  with  757 
deaths. 

"Among  the  2276  gunshot  wounds  entered  on  the  registers  during 
the  calendar  year  1899  were  197  injuries  of  the  head  and  face;  141  of 
these  were  flesh  wounds,  29  fractures  of  the  cranial  bones,  and  2"]  frac- 
tures of  the  bones  of  the  face.  No  flesh  wound  was  fatal,  but  the  eye 
had  to  be  enucleated  in  one  of  the  cases.  Fifteen  of  the  patients  with 
cranial  fractures  died  (i  of  these  in  1900)  and  5  recovered,  so  as  to  be 
able  to  resume  their  military  duties.  Depressed  bone  was  removed  in 
two  cases,  one  of  which  was  fatal.  Enucleation  of  the  eye  was  per- 
formed in  I  case,  and  the  wound  is  reported  as  having  been  closed  by 
sutures  in  i  case.  Of  those  who  suffered  fractures  of  the  facial  bones 
7  resumed  their  military  duties  and  2  died.  The  recorded  surgery  in 
fractures  of  these  bones  consisted  of  the  removal  of  fragments  of  bone 
and  of  portions  of  a  jNIauser  bullet  in  one  case,  which  ended  fatally ;  the 
removal  of  a  bullet  through  the  floor  of  the  mouth  in  one  case,  and 
enucleation  of  the  eye  in  one  case. 

"Of  60  cases  of  wound  of  the  neck  41  were  returned  to  duty  and  12 


GUNSHOT    WOUNDS    OF   THE    FACE.  187 

died.  Tlie  only  snrqical  work  recorded  was  the  removal  of  the  missile 
in  2  cases." 

The  fatalities  from  gunshot  fractures  of  the  bones  of  the  face  were 
therefore  13.50  per  cent. 

The  experiences,  then,  of  the  Spanish- American  war  prove  very 
conclusively  that  wounds  of  the  face  made  with  the  small-caliber  steel- 
jacketed  bullet  when  traveling'  at  its  maximum  velocity  cause  very  little 
fracture  or  comminution  of  the  bones,  and  rarely  produce  explosive 
effects ;  while  the  tissues  heal  kindly  and  cause  very  little  disfigurement 
or  deformity. 

The  steel-clad  bullet  is,  however,  sometimes  very  destructive  to  the 
soft  tissues  and  to  the  bones.  These  effects  are  stated  by  experts  to 
occur  when  the  missile  has  lost  its  high  velocity  and  the  rear  end  of  the 
bullet  begins  to  oscillate,  or  drops  slightly,  causing  it  to  strike  more  or 
less  with  its  side.  The  destruction  wrought  under  such  circumstances 
is  often  very  great,  especially  when  coming  in  contact  with  a  resistant 
tissue  like  bone.  Wounds  of  this  character  present  considerable  con- 
tusion of  the  soft  tissues  and  great  splintering  and  comminution  of  the 
bone. 

The  experiences  of  the  Boer  War  with  the  use  of  the  small-caliber 
jacketed  projectile  coincide  very  closely  with  those  of  the  Spanish- 
American  War. 

G.  W.  Alakins  in  his  work  entitled  "Surgical  Experiences  in  South 
Africa,"  which  covers  the  campaigns  of  1899-1900,  conveys  the  same 
ideas  as  to  the  character  of  the  wounds  produced  by  the  jacketed 
bullet : 

"The  most  severe  w'ounds  were  those  produced  by  the  unjacketed 
jNIartini-Henry  large-caliber  bullet  (480  grs.) — the  wounds  from  which 
were  about  10  per  cent,  of  the  whole — and  the  Mauser  and  Lee- 
Metford  bullets  (215  grs.)  which  had  been  tampered  with  by  cross- 
cutting  the  tips  and  slitting  them  down  to  the  mantle.  This  caused  the 
bullets  to  expand  on  impact,  and  greatly  increased  their  destructive 
effects." 

Such  treatment  of  bullets  is  an  abomination  and  a  grievous  sin 
against  humanity. 

Explosive  effects  were  rarely  observed  as  occurring  in  the  soft  parts 
only.  Makins  saw  no  cases  which  he  thought  substantiated  the  opinion 
that  such  effects  took  place  in  soft  tissues  only,  but  believed  that  in  most 
cases  presenting  explosive  effects  the  bullet  had  come  in  contact  with 
bone  or  else  the  missile  was  one  of  the  unjacketed  varieties  of  projectile. 

The  statistics  of  killed  and  wounded  in  this  campaign  comprise  the 
battles  of  Belmont,  Graspan,  Modder  River  and  Alagersfontein. 

"The  approximate  total  of  men  engaged  in  these  battles  was  12,420. 
Of   this   number    1959,   or    15.06  per   cent.,   were   reported    as    killed, 


l88  SURGERY    OF    THE    EACE,    MOUTH,    AND    JAWS. 

wounded,  or  missing:  thus,  killed,  315  or  2.53  per  cent. ;  wounded,  15 12 
or  12.17  P^r  cent. ;  missing,  132  or  1.06  per  cent.  If  to  these  figures  of 
fatalities  the  death  from  wounds  occurring  within  forty-eight  hours 
after  they  were  received  are  added  to  those  dying  on  the  field,  the  per- 
centage of  mortal  injuries  is  considerably  increased.  Thus,  if  the  num- 
bers are  massed  (omitting  the  missing)  we  find  that  in  the  four  battles 
1827  men  were  hit,  of  whom  315  or  17.24  per  cent,  were  killed.  Among 
the  wounded  carried  from  the  field,  however,  49  received  mortal  in- 
juries, and  if  these  be  added  to  the  315,  we  find  that  the  proportion  of 
mortal  injuries  reaches  19.92  per  cent. 

"The  proportion  of  men  killed  to  those  wounded  was  as  follows : 
Killed,  315;  wounded,  1512  or  i  to  4.8.  If  we  add  to  these  men  killed 
on  the  field  of  battle,  the  49  dying  in  the  next  forty-eight  hours,  the  pro- 
portion of  fatalities  is  increased  to  i  to  4.1=;.  The  higher  of  these  pro- 
portions is  certainly  the  correct  one." 

He  further  says  :  "With  regard  to  the  general  accuracy  of  the  num- 
bers given  above,  a  comparison  of  those  published  for  the  campaign  up 
to  September  15,  1900,  is  of  value,  as  the  two  series  substantially  tally. 

"Thus,  up  to  date  17,072  men  were  hit,  and  of  these  2998  were 
killed.    The  proportion  killed  to  wounded  was  therefore  i  to  4.69." 

These  figures  show  that  the  fatalities  were  a  trifle  lower  than  in  the 
Crimean  War,  and  nearly  correspond  with  those  observed  in  the  Franco- 
German  campaign.  He  thinks  that  in  view  of  these  facts  there  is  little 
ground  for  assuming  that  the  change  in  the  nature  of  the  weapons  em- 
ployed has  materially  influenced  the  deadliness  of  modern  warfare. 

In  a  few  cases  of  wounds  of  the  calf  of  the  leg  and  of  the  buttock 
which  came  under  his  observation,  fairly  typical  explosive  effects  were 
observed,  but  in  some  of  these  later  developments, — secondary  hemor- 
rhage, or  suppuration, — which  necessitated  opening  the  wound,  injury 
to  the  bone  was  discovered. 

Wounds  of  the  Face.  Wounds  of  the  Nose. — "Injuries  of  these 
parts  were  comparatively  common.  Those  which  involved  the  external 
parts  with  perforating  wounds  of  the  cartilages  were  remarkable  for 
their  sharp  limitation  and  simple  nature."  One  case  in  the  Irish  Hos- 
pital in  Bloemfontein  is  introduced  as  an  illustration,  in  which  at  the  end 
of  the  third  day  small  symmetrical  vertical  slits  in  each  ala  had  already 
healed  and  were  scarcely  visible. 

In  another  case  a  bullet  was  retained  in  the  upper  portion  of  the 
nasal  cavity.  This  accident  was  naturally  a  rare  one ;  in  another  in- 
stance the  bullet  had  only  retained  sufficient  force  to  insert  itself  neatly 
between  the  bones. 

Wounds  crossing  the  nasal  fossae  were  comparatively  common. 
Interference  with  the  sense  of  smell  often  results  from  this  form  of 
injury. 


GUNSHOT    WOUNDS    OF    THE    FACE.  189 

Wounds  of  the  Molar. — Wounds  of  the  malar  bone  were  not  infre- 
quent. The  small  amount  of  splintering  was  somewhat  remarkable  con- 
sidering the  density  in  structure  of  this  bone.  "In  this  particular  the 
behavior  of  the  malar  corresponded  with  what  was  observed  in  the  flat 
bones  in  general,  viz.  the  capacity  of  the  hard  edge  of  the  bone  to  check 
the  course  of  the  bullet,  and  cause  considerable  deformity  and  fissuring 
of  the  mantle." 

JJ'ouiids  of  tJic  Upper  Jozc. — "A  large  number  of  tracks  crossing 
the  antrum  transversely,  obliquely,  or  vertically  were  observed.  In  the 
first  the  nasal  cavity,  in  the  others  the  orbital  or  buccal  cavity,  was 
generally  concurrently  involved.  It  was  somewhat  striking  that  trouble 
was  never  observed,  either  immediate  or  remote,  from  these  perforations 
of  the  antrum.  If  hemorrhage  into  the  cavity  occurred,  it  gave  rise  to 
no  ultimate  trouble.  An  instance  was  never  observed  of  secondary  sup- 
puration, even  in  cases  where  the  bullet  entered  or  escaped  through  the 
alveolar  process  with  considerable  local  comminution.  The  branches 
of  the  second  division  of  the  fifth  nerve  were  sometimes  implicated.  In 
one  instance  a  bullet  traversed  and  cut  away  a  longitudinal  groove  in  the 
bones,  extending  from  the  posterior  margin  of  the  hard  palate  and  ter- 
minating by  a  wide  notch  in  the  alveolar  process." 

A  good  example  of  troublesome  transverse  wounds  of  the  bones  of 
the  face  is  afforded  by  the  following  instances  : 

"Entry  (Alauser),  through  the  left  malar  eminence,  i  inch  below 
and  external  to  the  external  canthus  of  the  eye ;  exit,  a  slightly  curved 
transverse  slit  in  the  lobe  of  the  right  ear. 

"The  injury  was  followed  by  no  signs  of  orbital  concussion,  and  no 
loss  of  consciousness.  There  was  free  bleeding  from  both  external 
wounds  and  from  the  nose.  The  sense  of  smell  was  unaffected,  but  taste 
was  impaired,  and  there  was  loss  of  tactile  sensation  in  the  teeth  on  the 
left  side,  also  on  the  hard  palate.  There  was  no  evidence  of  fracture  of 
the  neck  of  the  mandible,  nor  of  the  external  auditory  meatus,  but  there 
was  considerable  difficulty  in  opening  the  mouth  widely  or  protruding 
the  lower  jaw.  The  latter  difficulty  persisted  for  some  time,  and  was 
still  present  when  patient  was  last  seen. 

IVonnds  of  the  Mandible. — "Fractures  of  the  lower  jaw  were  fre- 
quent and  offered  some  peculiarities,  the  chief  of  which  were  the  lia- 
bility of  any  part  of  the  bone  to  be  damaged,  and  in  the  absence  of  the 
obliquity  between  the  cleft  in  the  outer  and  inner  tables  so  common 
in  the  fractures  seen  in  civil  practice. 

"Fracture  of  the  neck  of  the  condyle  was  observed  three  times ;  in 
each  instance  permanent  stiffness  and  inability  to  open  the  mouth  re- 
sulted. This  stiffness  was  of  a  degree  sufficient  to  raise  the  question 
whether  the  best  course  in  such  cases  would  not  be  to  cut  down  pri- 
marily and  remove  a  considerable  number  of  loose  fragments,  and 
thus  diminish  the  amount  of  callus  likely  to  be  thrown  out. 


igO  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

"Fractures  of  the  ascending  ramus  and  body  were  more  frequent. 
They  were  accompanied  by  considerable  comminution,  but  all  that  I 
observed  healed  remarkably  well,  and  in  good  position,  in  spite  of  the 
fact  that  many  of  the  patients  objected  to  wearing  any  form  of  splint. 

"The  most  noticeable  feature  was  the  occurrence  of  notched  frac- 
tures. When  the  fractures  were  at  the  lower  margin  of  the  bone  the 
buccal  cavity  occasionally  escaped  in  spite  of  considerable  comminution, 
the  latter  confining  itself  to  the  basal  portion  of  the  bone. 

"When  the  base  of  the  teeth,  or  the  alveolus,  was  struck,  a  wedge 
was  broken  away,  and  from  the  apex  of  the  resulting  gap  a  fracture 
extended  to  the  lower  margin  of  the  bone." 

When  fractures  of  the  latter  nature  resulted  from  vertically  cours- 
ing bullets  much  trouble  often  ensued.  Two  cases  are  presented  in 
illustration : 

"Entry  (Mauser),  through  the  lower  lip :  the  ballet  struck  the  base 
of  the  right  lateral  incisor  and  canine  teeth,  knocked  out  a  wedge,  and 
becoming  slightly  deflected,  cut  a  vertical  groove  to  the  base  of  the 
mandible :  exit,  in  left  submaxillary  triangle.  The  bullet  subsequently 
re-entered  the  chest  wall  just  below  the  clavicle,  and  escaped  at  the 
anterior  axillary  fold.  The  appearance  of  these  second  wounds  sug- 
gested only  slight  setting  up  of  the  bullet :  the  original  impact  was  no 
doubt  of  an  oblique  or  lateral  character. 

"The  injury  was  followed  by  free  hemorrhage  and  remarkably 
abundant  salivation  and  great  swelling  of  the  floor  of  the  mouth. 

"The  patient  could  not  bear  any  form  of  apparatus,  but  was  assidu- 
ous in  washing  out  his  mouth,  and  made  a  good  recovery,  the  fragments 
being  in  good  apposition." 

"Entry  (Mauser)  over  the  right  malar;  the  bullet  carried  away  all 
the  upper  and  lower  molars,  fractured  the  mandible,  and  was  retained 
in  the  neck. 

"A  fortnight  later  an  abscess  formed  in  the  lower  part  of  the  neck, 
which  was  opened  and  portions  of  the  mantle  and  leaden  core,  together 
with  numerous  fragments  of  the  teeth,  removed.  The  bullet  had 
undergone  fragmentation  on  impact,  probably  on  the  last  tooth  of  the 
mandible,  and  still  retained  sufiicient  force  to  enter  the  neck. 

"This  case  afifords  an  interesting  example  of  the  transmission  of 
force  from  the  bullet  to  the  teeth,  and  bears  on  the  theory  of  explosive 
action." 

He  further  says:  "In  the  treatment  of  fractures  of  the  upper  jaw, 
surgical  interference  was  rarely  needed.  The  removal  of  loose  frag- 
ments is  necessary  in  all  cases  in  which  the  buccal  cavity  is  involved. 
Experience  in  fracture  of  the  limbs  has  shown  a  tendency  to  'quiet" 
necrosis  when  comminution  was  severe,  in  spite  of  primary  union.  This 
is  no  doubt  dependent  on  the  very  free  separation  of  the  fragments  on 


GUNSHOT    WOUNDS    OF    THE    FACE.  IQI 

the  entry  and  exit  aspects  from  their  periosteum.  In  the  case  of  the 
mandible,  considerable  necrosis  is  inevitable,  and  much  time  is  saved  by 
primary  removal  of  all  actually  loose  fragments. 

"A  splint  of  the  ordinary  chin-cap  type  with  a  four-tailed  bandage 
meets  all  requirements,  but  the  patients  often  object  to  them.  Cases  in 
which  the  fragments  could  be  fixed  by  wiring  the  teeth  were  not  com- 
mon, as  the  latter  had  so  often  been  carried  away.  The  usual  precau- 
tions as  to  maintaining  oral  asepsis  were  especially  necessary." 

The  results  of  fractures  of  the  mandible  were,  in  so  far  as  his 
experience  went,  remarkably  good,  as  deformity  was  seldom  consider- 
able. The  absence  of  obliquity  and  the  effect  of  primary  local  shock 
were  no  doubt  favorable  elements,  little  primary  displacement  from 
muscular  action  occurring. 

"Wounds  of  the  neck  healed  readily,  and  the  same  was  noticeable 
of  the  lips.  Wounds  of  the  tongue  healed  with  remarkable  rapidity 
when  of  the  simple  perforating  type,  often  with  little  or  no  swelling  or 
evidence  of  contusion.  At  the  end  of  a  few  days  it  was  often  difficult 
to  localize  them. 

"In  connection  with  this  subject  a  remarkable  case  which  occurred 
at  the  fight  at  Koodoosberg  Drift  is  worthy  of  mention,  although  the 
projectile  was  a  shell  fragment  and  not  a  bullet  of  small  caliber. 

"A  Highlander  was  the  unfortunate  possessor  of  an  entire  set  of 
upper  teeth  set  in  a  gold  plate.  A  small  fragment  of  a  shell  perforated 
the  upper  lip  by  an  irregular  aperture,  and  struck  the  teeth  in  such 
manner  as  to  turn  the  posterior  edge  of  the  plate  toward  the  tongue, 
which  latter  was  cut  into  two  halves  transversely  through  to  the  base. 

"The  patient  asserted  that  the  plate  had  been  driven  down  his 
throat,  but  nothing  was  palpable  either  in  the  fauces  or  on  external  ex- 
amination of  the  neck.  He  spoke  distinctly,  but  there  was  a  dysphagia 
as  far  as  solids  were  concerned. 

"On  the  second  day  swelling  of  the  neck  due  to  early  cellulitis 
developed,  especially  on  the  left  side,  and  signs  of  laryngeal  obstruc- 
tion became  prominent.  Chloroform  was  administered,  but  on  the 
introduction  of  the  finger  into  the  fauces,  respiration  failed  and  a  hasty 
tracheotomy  had  to  be  performed.  No  foreign  body  was  palpable  with 
the  finger  in  the  pharynx. 

"Tracheitis  and  septic  pneumonia  developed,  and  the  man  died  of 
acute  septicemia  thirty-six  hours  later.  Death  occurred  just  as  the 
division  received  marching  orders,  and  no  post-mortem  examination 
was  made.  As  a  result  of  palpation  at  the  time  of  tracheotomy,  the 
probabilities  seemed  against  the  presence  of  the  tooth-plate  in  the 
pharynx,  but  the  absence  of  positive  evidence  scarcely  allows  the  case  to 
be  certainly  classed  as  one  of  the  cellulitis  and  septicemia  secondary  to 
wound  of  the  tongue." 


192  SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 

Leaden  bullets  penetrating  the  face  sometimes  lodge  in  the  antrum 
or  nose,  and  remain  there  for  a  considerable  time,  and  may  finally  be- 
come encysted. 

Fig.  63,  a  Roentgen-ray  picture  of  the  face  of  a  soldier  recently 
returned  from  the  War  in  the  Philippines,  shows  a  leaden  bullet  of 

Fig.  63. 


Bullet  lodged  in  the  Malar  Process  of  the  Superior  Maxillary. 

small  caliber  lodged  in  the  malar  process  of  the  superior  maxillary 
bone.    The  missile  entered  from  the  opposite  side. 

Fig.  64,  also  a  Roentgen-ray  picture,^shows  another  leaden  bullet, 
considerably  deformed,  which  entered  the  front  of  the  face  just  below 
the  orbit  and  lodged  in  the  muscles  of  the  soft  palate,  and  could  be  felt 


GUNSHOT    WOUNDS    OF    THE    FACE.  I93 

in  these  tissues  by  passing  the  linger  into  the  mouth.  Wliile  making 
such  an  examination,  the  missile  was  dislodged  and  two  days  thereafter 
it  fell  into  the  fauces  through  the  naso-pharyngcal  opening  and  was 
spit  up  by  the  patient. 

Fig.  64. 


Bullet  lodged  in  Muscles  of  the  Soft  Palate. 

Gunshot  wounds  of  the  superior  maxilla,  occurring  through  the 
mouth,  are  usually  the  result  of  a  suicidal  intention,  though  such 
injuries  do  occasionally  occur  from  accidental  causes,  and  are  usually 
immediately  fatal.  Sometimes,  however,  the  injury  is  not  very  severe, 
and  the  patient  recovers.    Fig.  65  is  the  cast  of  a  case  from  the  writer's 

14 


194 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


collection,  showing  result  of  gunshot  injury  of  the  upper  jaw  from  the 
accidental  discharge  of  a  shotgun. 

Missiles  striking  the  lower  jaw  invariably  produce  fracture,  and 
often  considerable  comminution  and  loss  of  tissue,  while  hemorrhage 
is  quite  likely  to  be  severe,  especially  when  the  facial  artery  is  involved 
in  the  wound. 

Symptoms. — The  immediate  symptoms  of  gunshot  injuries  are 
pain,  shock,  and  hemorrhage. 

Pain  as  a  first  symptom  is  rarely  absent.  The  degree  of  pain  will 
depend  upon  the  location  of  the  wound,  its  nature,  the  tissues  involved, 
and  the  mental  condition  of  the  individual.     Nerves  when  injured  or 


Fig.  6= 


Result  of  Gunshot  In"jurv  of  the  Upper  Jaw. 


contused  are  productive  of  severe  pain,  which  is  referred  generally  to 
the  region  supplied  by  the  injured  nerve.  When  a  nerve  is  completely 
divided,  there  is  a  total  loss  of  sensation  in  the  part  supplied,  and  more 
or  less  complete  paralysis  of  motion. 

The  degree  of  shock  depends  upon  the  temperament  of  the  indi- 
vidual, the  physical  condition  at  the  time  of  the  injur}-,  and  the  region 
of  the  body  in  which  the  wound  has  been  received. 

In  wounds  of  the  abdomen,  shock  is  more  profound  and  persistent 
than  in  wounds  in  any  other  part  of  the  body.  Injuries  which  pro- 
duce considerable  splintering  and  comminution  of  the  long  bones  are 
usually  followed  by  shock  of  severe  degree. 

Hemorrhasre  will  be  slight  or  severe,  according  to  the  extent  of 


GUNSHOT    WOUNDS   OF   THE    FACE. 


195 


the  injury  to  large  blood-vessels  and  the  vascularity  of  the  soft  tissues 
involved.     Wounds  of  large  arterial  trunks  speedily  terminate  fatally. 

Treatment. — The  first  thing  to  be  done  in  gunshot  wounds  of  the 
face  is  to  arrest  the  hemorrhage  if  it  is  in  any  way  alarming. 

The  hemorrhage  may  be  controlled  by  tying  the  bleeding  arteries 
where  possible  to  reach  them,  and,  when  inaccessible,  by  packing  the 
wound  with  antiseptic  gauze;  where  packing  cannot  be  utilized,  as  in 
the  case  of  large  surface  wounds,  or  where  portions  of  the  face  have 
been  carried  away  by  fragments  of  shell,  stone,  etc.,  recourse  must  be 
had  to  styptics.  Compresses,  wrung  out  of  hot  antiseptic  solutions 
preferably,  should  be  applied  as  hot  as  can  be  borne.     Persulfate  of 

Fig.  66. 


Gunshot  Fracture  of  Lower  Jaw  with   Loss  of   Boxe  from  A  to  B.    Treated  by  Inter- 
dental Splint  Bridge.     (After  Patterson.) 


iron  is  frequently  used  in  these  cases,  but  it  has  the  disadvantage  of 
occasionally  causing  extensive  sloughs,  and  is  sometimes  followed  by 
secondary  hemorrhage. 

The  missile  should  be  searched  for  and  removed  as  soon  as  pos- 
sible, together  with  all  detached  fragments  of  bone,  and  foreign  sub- 
stances, which  may  have  entered  the  wound.  Loose  fragments  of 
bone  which  are  still  attached  to  the  soft  tissues  should  under  no 
circumstances  be  removed,  but  placed  as  nearly  as  possible  in  their 
normal  positions,  and  retained  by  means  of  sterilized  packing  or  other 
suitable  support 

Bullet  injuries  of  the  upper  part  of  the  face,  which  at  first  seem 
likely  to  result  in  extensive  deformity,  often  recover  with  so  little  dis- 
figurement as  to  be  a  surprise  to  all  concerned,  provided  care  has  been 
taken  to  preserve  every  fragment  of  bone  which,  by  reason  of  attach- 


196  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

ment  to  the  soft  tissue,  gives  hope  of  sustaining  its  vitaHty  and  making 
a  union  with  its  fellows. 

Gunshot  injuries  involving  the  lower  jaw  are  usually  complicated 
with  multiple  fractures,  great  comminution,  and  many  times  with  ex- 
tensive loss  of  bone-tissue,  which  was  carried  away.  The  successful 
management  of  these  cases  will  depend  largely  upon  the  skill  and  the 
inventive  genius  of  the  surgeon.  A  wise  conservatism,  however,  is 
nowhere  of  greater  value  than  in  the  treatment  of  this  class  of  injuries. 

In  those  cases  where  there  has  been  a  considerable  loss  of  bone- 
tissue,  it  is  important  that  some  kind  of  a  support  be  applied  to  pre- 
vent the  free  ends  of  the  jaw  from  falling  together,  which  would  other- 
wise cause  a  serious  disfigurement,  and  destroy  the  occlusion  of  the 
remaining  teeth. 

When  teeth  remain  on  either  side  of  the  gap,  gold  or  platinum 
bands  can  be  titted  to  them,  and  extension  and  immobility  secured  by 
soldering  a  gold  wire  to  the  approximal  surfaces  of  the  bands,  and  the 


Fig.  67. 


Interdental  Splint  Bridge.     (After  Patterson.) 

appliance  cemented  to  the  teeth  with  the  ordinary  oxyphosphate 
cement.  To  provide  for  further  extension  or  approximation,  the  wire 
can  be  divided  in  the  center,  and  be  fitted  with  a  double  screw  nut,  and 
the  appliance  lengthened  or  shortened  at  the  will  of  the  operator. 
Figs.  66,  67,  illustrate  a  case  of  this  character  reported  by  Patterson, 
in  which  a  large  fragment  of  bone  was  lost  by  a  gunshot  wound,  and 
the  contour  of  the  jaw  restored  and  the  remaining  fragments  held  in  a 
norm-al  position  by  an  interdental  splint  bridge  cemented  to  the  remain- 
ing teeth. 

If  the  jaw  is  edentulous,  the  same  result  may  be  obtained  by 
introducing  a  gold  wire  of  the  proper  length,  having  a  collar  of  the 
same  material  attached  one-eighth  of  an  inch  from  each  end,  and  this 
inserted  between  the  free  ends  of  the  jaw,  holes  having  been  made  in 
them  for  the  reception  of  the  wire,  and  the  tissues  closed  over  it.  as 
suggested  by  Cervera,  Figs.  68,  69.  Such  an  appliance  will  generally 
become  encysted,  and  is  then  not  likely  to  give  future  inconvenience. 

After  the  wound  has  healed  and  the  cicatrix  hardened,  the  gap 


GUNSHOT    WOUNDS    OF    THE    FACE. 


197 


may  be  filled  with  a  suitable  piece  of  bridge-work,  or  a  removable 
denture. 

Loss  of  extensive  portions  of  the  superior  maxilla  is  a  not  infre- 
quent result  of  g'unshot  injuries  upon  the  field  of  battle,  from  accidents 
while  hunting,  and  from  attempts  at  suicide. 

Restoration  of  the  contour  of  the  face  can  many  times  be  accom- 
plished— when  the  soft  parts  are  intact,  or  can  be  made  so  by  a  plastic 
operation — by  the  construction  of  supports  to  the  soft  tissues  repre- 
senting the  portions  of  lost  bone,  and  attaching  them  to  the  remaining 
teeth. 


Fig.  68. 


Fig.  69. 


Prosthetic  Wire  Arch  for  Partial  Rksection  of  Lower  Jaw.     (After  Cervera.) 


Attempts  have  been  made  to  bury  such  appliances  in  the  soft 
tissues,  but  with  only  indifferent  success,  as  sooner  or  later  they  cause 
ulceration,  and  have  to  be  removed.  The  materials  which  have  been 
used  for  this  purpose  are  vulcanite,  gold,  platinum,  and  aluminum. 

One  such  case  as  first  described,  in  which  the  superior  maxillary 
bone  was  lost  from  the  median  line  back  to  the  second  molar,  involving 
the  palate  process  nearly  to  the  median  line,  and  the  body  of  the  bone 
to  the  orbital  plate,  was  successfully  treated  by  the  writer  by  means  of 
an  appliance  constructed  of  gold  and  vulcanite  combined,  and  retained 
in  position  by  clasps  attached  to  the  remaining  teeth. 

The  discussion  of  fractures  of  the  maxillar)^  bones  and  their  treat- 
ment will  be  reserved  for  a  later  chapter. 


CHAPTER    XXI. 
FRACTURES   OF  THE  INFERIOR   MAXILLA. 

Definition. — Fracture  (Lat.  fractnra,  a  break).  The  breaking 
of  a  bone,  either  by  external  force  or  by  the  action  of  the  muscles  of 
the  body. 

Plate  II  is  a  Roentgen-ray  picture,  showing  a  simple  fracture  of 
the  ulna.  (From  the  collection  of  the  U.  S.  Army  General  Hospital, 
Presidio  of  San  Francisco.) 

Fractures  of  the  jaws  are  of  quite  common  occurrence,  and  are 
generally  the  result  of  blow^s  upon  the  face  from  the  fist,  kicks  of  large 
animals,  the  impact  of  some  heavy  missile  propelled  with  considerable 
velocity;  gunshot  injuries;  the  extraction  of  teeth;  a  fall  from  a  bicycle, 
a  horse,  a  building,  or  other  considerable  height;  passage  of  a  wheel 
over  the  face;  injuries  from  passenger  or  freight  elevators,  or  other 
crushing  force. 

Fractures  of  the  superior  maxilla  are  much  less  frequent  than  frac- 
tures of  the  inferior  maxilla,  on  account  of  the  fact  that  the  superior 
maxillary  bones  are,  by  reason  of  their  location  and  shape,  less  ex- 
posed to  injury.  When  fractures  of  these  bones  do  occur,  they  are 
generally  the  result  of  a  severe  traumatism. 

The  inferior  maxilla,  from  its  size,  shape,  and  location,  is  more 
often  fractured  than  any  other  bone  of  the  face.  In  size,  it  is  the 
largest  of  all  the  bones  of  the  face.  Its  shape  makes  it  liable  to  fracture 
in  the  anterior  portion  or  at  the  angle,  when  blows  are  received  upon 
the  side  of  the  face,  and  through  the  ramus  or  at  the  neck  of  the  con- 
dyle when  the  blow  is  received  upon  the  chin. 

The  weakest  point  of  the  lower  jaw  is  just  anterior  to  the  mental 
foramen,  through  the  alveolus  of  the  cuspid  tooth.  In  edentulous 
jaws  this  weak  point  would  be  through  the  mental  foramen  (Fig.  70). 

Its  location  is  exposed,  and  it  is  therefore  more  liable  to  receive 
an  injury  than  those  parts  which  are  better  protected.  Fractures  of 
the  lower  jaw  are  ten  times  more  frequent  in  males  than  in  females. 
This  is  largely  due  to  the  difference  in  the  occupations  and  the  degree 
of  exposure  to  accident  between  the  sexes. 

Fractures  of  the  maxillary  bones  are  classed  under  two  general 
forms,  viz:  Simple  and  Coniplicafcd. 
198 


FRACTURES    OF    THE    INFERIOR    MAXILLA. 


199 


FRACTURES    OF   THE    INFERIOR    MAXILLA. 


201 


Siviplc  fractures  are  those  in  which  there  is  a  single  fracture  of 
the  bone,  without  injury  or  break  in  the  continuity  of  the  external 
tissues. 

Coinplicafcd  fractures  include  all  other  conditions  associated  with 
a  fracture  of  the  bone,  such  as  injuries  to  the  external  tissues,  to  ves- 
sels, to  nerves,  to  teeth,  to  a  comminuted  condition  of  the  bone  itself, 
or  any  other  condition  which  complicates  a  simple  fracture. 

Complicated  fractures  may  be  divided  into  Multiple,  Comminuted, 
and  Compound. 

Multiple  fractures  include  those  in  which  there  is  more  than  one 
break  in  the  continuity  of  the  bone.  Double  and  triple  fractures 
would  be  classed  under  this  head. 

Fig.  70. 


The  Inferior  Maxillary  Bone,  External  Surface  of  the  Right  Side. 
M,  Mental  process;    I,  Incisive  fossa;    F,  Mental  foramen;    L,  External  oblique  line;    G,  Groove 
for  facial  artery  ;  A,  Anterior  or  coronoid  process  ;  P,  Posterior  or  condyloid  process. 

Comminuted  fractures  are  the  result  of  crushing  injuries  or  gun- 
shot wounds,  which  cause  splintering  and  crushing  of  the  bone  into 
small  fragments. 

Compound  fractures  are  those  which  have  associated  with  them 
injuries  of  the  soft  tissues,  causing  exposure  of  the  fractured  ends  of 
the  bone. 

Fractures  of  the  Alveolar  Process. — The  most  common  frac- 
tures of  the  jaw  are  those  of  the  alveolar  process,  and  they  are  gen- 
erally associated  with  the  extraction  of  teeth.  These  fractures  rarely 
involve  more  of  the  process  than  the  external  plate  lying  immediately 
over  the  roots  of  the  tooth  extracted,  and  perhaps  a  small  portion 
extending  over  those  adjacent  to  it. 


202 


SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 


Fractures  of  the  alveolar  process  frequently  occur  as  a  result  of 
falls  or  of  blows  upon  the  chin  which  have  an  upward  direction,  driving 
the  teeth  into  their  sockets,  and  splitting  the  process  on  a  line  with  the 
alveoli.  These  accidents  most  frequently  occur  among  men  engaged 
in  the  building  trades,  as  the  result  of  falls  from  buildings  and 
scaffolding. 

When  this  accident  occurs  to  the  upper  jaw,  the  external  plate  of 
the  alveolar  process  is  usually  the  part  to  give  way;  the  internal  plate 
is  supported  by  the  palate  process,  hence  its  greater  power  of  resist- 
ance. When  the  same  accident  occurs  to  the  lower  jaw,  the  external 
and  internal  plates  of  the  process  are  usually  both  fractured  and  sep- 
arated. 

Fractures  of  the  Body  of  the  Lower  Jaw. — Fractures  of  the  body 
of  the  bone  most  frequently  occur  as  foUow^s  : 

First.     In  the  region  of  the  cuspid  tooth  (Fig.  71,  i). 

Second,     At  points  between  the  cuspid  tooth  and  the  angle  of  the 

jaw  (2). 

Fig.  71. 


3       ~T. 

Fracture  of  the  Body,  Condyles,  and  Coronoid  Process  of  the  Lower  Jaw. 
(After  Fergusson.) 


Third.  In  locations  between  the  symphysis  of  the  jaw^  and  the 
cuspid  tooth  (3). 

Fourth.     At  the  angle  of  the  jaw  (4). 

Fifth.     Through  the  symphysis  (5). 

Sixth.     At  points  through  the  ascending  ramus  (6). 

Seventh.     At  the  neck  of  the  condyle  (7). 

Eighth.     Through  the  coronoid  process  (8). 

Fractures  located  above  the  angle  are  exceedingly  rare.  Out  of 
fifty-five  cases  of  fracture  of  the  low"er  jaw  reported  by  Hamilton,  only 
three  were  above  the  angle. 

Fractures  of  the  body  of  the  jaw,  through  the  cuspid,  bicuspid,  or 
molar  regions,  the  angle  or  symphysis,  are  usually  the  result  of  injuries 
received  upon  the  side  of  the  face,  while  fractures  of  the  ascending 
ramus  and  the  neck  of  the  condyle  are  usually  caused  by  injuries 
received  upon  the  chin, — as  blows  or  falls.  Out  of  the  fifty-five  cases 
just  mentioned  as  reported  by  Hamilton,  four  only  were  through  the 


FRACTURES    OF    THE    INFERIOR    MAXILLA, 


203 


symphysis.     The  great  majority  of  the  fractures  of  the  lower  jaw  are 
compounded,  generally  into  the  mouth. 

Fig.  ']2  is  a  Roentgen-ray  picture  showing  a  fracture  of  the  body 
of  the  lower  jaw  just  anterior  to  the  angle,  with  displacement  of  the 

Fig.  72. 


Fracture  of  the  Lower  Jaw  anterior  to  the  Angle. 

ramus  into  the  mouth  and  forward,  causing  the  fractured  ends  of  the 
bone  to  lap  upon  each  other.  It  will  be  noticed  also  that  th^  fracture  is 
vertical.  (From  the  collection  of  the  U.  S.  Army  General  Hospital. 
Presidio  of  San  Francisco.) 


204 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


Displacements. — In  fractures  through  the  symphysis,  displace- 
ment is  usually  very  slight,  on  account  of  the  attachment  of  the  muscles 
of  the  lateral  halves  of  the  jaw,  and  their  equalized  action.  Such  a 
fracture  may  occur  and  not  be  recognized  by  the  patient,  except  from 
the  crepitation  produced  when  attempting  to  masticate  food. 

In  fractures  at  the  neck  of  the  condyle,  the  displacement,  as  a 
rule,  is  not  very  great.  The  direction  of  the  displacement  when  it 
does  occur  will  be  forward,  on  account  of  the  action  of  the  external 
pterygoideus,  which  drags  the  body  in  this  direction. 

Fractures  at  the  symphysis,  through  the  ascending  ramus,  or  the 
neck  of  the  condyle,  are  rarely  compounded  into  the  mouth;  fractures 
at  these  locations  are,  however,  sometimes  compounded  externally 
from  laceration  of  the  covering  tissues  at  the  point  where  the  injury 
was  received. 

Fig.  -jz. 


Fractures  of  the  Lower  Jaw  with  Displacement.     (After  Malgaigne.) 


Simple  fractures  are  not  subject  to  the  same  amount  of  displace- 
ment as  are  multiple  and  compoimd  fractures. 

A  simple  fracture  through  the  cuspid  regions  will  not  cause  so 
great  a  displacement  as  when  the  same  character  of  fracture  is  com- 
pounded into  the  mouth,  for  the  covering  tissues  combat  to  a  certain 
extent  the  tendency  of  the  muscles  to  draw  the  ends  of  the  fractured 
bone  out  of  position.  When  the  continuity  of  the  covering  tissues  is 
broken,  the  muscles  have  full  play,  and  cause  a  displacement  com- 
mensurate with  the  location  and  the  character  of  the  injury. 

Multiple  fractures  are  subject  to  the  greatest  amount  of  displace- 
ment. Fractures  occurring  upon  both  sides  of  the  jaw  at  the  same 
time  always  present  the  greatest  degree  of  displacement. 

In  fractures  occurring  in  the  anterior  portion  of  the  jaw,  and  upon 
both  sides,  through  the  cuspid  or  bicuspid  region,  the  central  portion 
would  be  dragged  downward  and  backward  by  the  action  of  the  genio- 
hyoid, genio-hypoglossus,  and  digastric  muscles. 

When  the  fracture  occurs  at  the  cuspid  region,  and  through  the 
body  or  ascending  ramus,  the  intermediate  fragment  will  be  displaced 


FRACTURES    OF    THE    INFERIOR    MAXILLA. 


20  = 


inward  by  the  action  of  the  niylo-hyoideus,  upward  by  the  masseter, 
and  forward  by  the  action  of  the  external  pterygoideus  (Fig.  73). 

In  single  compound  fractures  occurring  in  the  region  of  the 
cuspid  tooth,  or  just  anterior  or  posterior  to  it,  the  displacement  is 
sometimes  considerable. 

Lines  of  Fracture. — The  lines  of  fracture  may  be  vertical,  oblique, 
or  horizontal.  It  sometimes  occurs,  however,  that  the  lines  of  frac- 
ture may  be  combined,  as,  for  instance,  vertical  and  oblique,  vertical 
and  horizontal,  double  oblique,  etc. 

When  the  fracture  is  through  the  symphysis,  it  is  almost  always 
vertical  (Fig.  74).  In  the  four  cases  of  this  class  reported  by  Hamilton, 
the  fractures  were  all  vertical.  Two  cases  seen  by  the  writer,  occurring 
in  elderly  people,  were  both  vertical. 

Fractures  of  the  alveolar  process  are  generally  vertical  and  oblique 
combined;  as,  for  instance,  when  the  external  plate  of  the  process  is 
split  off  in  the  extraction  of  teeth,  or  as  the  result  of  upward  blows 
upon  the  chin. 

Fig.  74. 


Fracture  through  the  Symphysis.     (After  Angle. 


The  great  majority  of  the  fractures  of  the  body  of  the  bone,  how- 
ever, are  oblique.  According  to  ^lalgaigne,  the  thickness  of  the  bone 
is  also  divided  obliquely,  so  that  generally  the  fracture  occurs  at  the 
expense  of  the  internal  plate  of  the  anterior  fragment  and  the  external 
plate  of  the  posterior  fragment.  \\'hen  the  fracture  is  very  oblique, 
there  is  usually  considerable  overlapping  and  locking,  making  reduc- 
tion sometimes  verv  difficult,  as  in  Fig.  73. 

Out  of  forty  cases  of  fracture  of  the  body  of  the  bone  reported  by 
Hamilton,  eighteen  were  demonstrated  to  be  single  oblique,  and  thir- 
teen double  and  triple  fractures. 

Nearly  all  fractures  of  the  body  of  the  bone  have  a  perpendicular 
direction  through  the  alveolar  process.     The  direction  of  the  line  of 


206  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

fracture  outside  of  this  may  be  obliquely  forward  or  backward.  There 
is  considerable  difficulty,  however,  in  positively  demonstrating  this  fact 
in  the  living  subject,  and  as  the  mortality  from  this  class  of  injury  is 
very  low,  the  opportunities  for  post-mortem  examinations  are  rare. 

The  specimens  preserved  in  the  various  museums  would  seem, 
however,  to  corroborate  the  general  opinion  that  the  majority  of  the 
fractures  through  the  body  of  the  bone  are  oblique.  Heath  mentions 
a  case  in  the  museum  of  King's  College,  London,  as  being  obliquely 
forward  and  backward. 

Symptoms. — The  symptoms  of  fracture  of  the  lower  jaw  are  gen- 
erally well  marked,  except  in  simple  fractures  through  the  symphysis. 
The  special  diagnostic  signs  of  fracture  are  crepitus,  more  or  less  de- 
formity in  the  contour  of  the  lower  part  of  the  face,  and  unnatural  or 
excessive  mobility.  Pain  is  always  present,  and  is  increased  by  the 
movements  of  the  jaw.  In  the  majority  of  the  cases,  the  mucous  mem- 
brane is  lacerated,  giving  rise  to  more  or  less  hemorrhage.  The 
saliva  is  secreted  in  excessive  quantity,  and,  being  mixed  with  dis- 
charges from  the  wound,  decomposes  and  causes  a  fetid  odor  of  the 
breath.  Changes  in  the  normal  occlusion  of  the  teeth  are  generally 
well  marked  at  the  point  of  injury.  The  teeth  upon  either  side  of  the 
fracture  are  commonly  loosened,  and  sometimes  entirely  luxated. 
Erichsen  mentions  a  case  in  which  the  tooth  had  been  detached  from 
its  alveolus  and  become  lodged  between  the  fragments  of  the  jaw,  pre- 
venting adjustment  of  the  fracture  until  it  was  found  and  removed. 

Considerable  inflammation,  as  a  rule,  follows  fracture  of  the  jaw, 
accompanied  by  swelling  and  infiltration  of  the  face  and  neck,  and 
followed  not  infrequently  by  troublesome  abscesses  and  necrosis  of 
splintered  portions  of  the  bone.  This  is  explained  by  the  fact  that 
such  fractures  are  generally  compounded  and  often  comminuted, 
making  infection  certain. 

Among  the  possible  complications  of  fractures  of  the  lower  jaw 
are  hemorrhage  from  wounding  the  inferior  dental  arter\',  paralysis  of 
the  lower  lip  and  chin  from  injury  of  the  inferior  dental  nerve,  salivary 
fistula,  abscess,  necrosis,  septicemia,  and  pyemia. 

Diagnosis. — The  diagnosis  of  fractures  of  the  lower  jaw  is  gen- 
erally a  simple  matter,  but  occasionally  difficulty  is  experienced  in 
locating  the  exact  seat  of  the  fracture,  especially  if  it  is  a  simple  one, 
without  displacement.  Wlien  doubt  exists,  seat  the  patient  upon  a  low 
chair,  taking  a  position  behind  him;  then  grasp  the  jaw  with  both 
hands,  the  thumbs  upon  the  ends  of  the  teeth  and  the  fingers  under- 
neath the  chin,  and  test,  by  alternately  depressing  and  elevating  first 
one  side,  then  the  other.  If  fracture  exists,  crepitation  will  be  dis- 
covered at  the  point  of  injur}^  If  the  fracture  is  through  the  coronoid 
process  only,  the  diagnosis  will  be  made  from  the  inability  of  the 
patient  to  properly  close  the  jaw  upon  this  side. 


FRACTURES    OF    THE    INFERIOR    MAXILLA.  2.0"] 

Prognosis. — The  prognosis  of  fracture  of  the  lower  jaw  is,  as  a 
general  rule,  very  favorable.  The  mortality  from  this  injury  is  ex- 
ceedingly low;  a  fatal  termination  would  be  due,  in  all  prol^ability, 
to  other  conditions  arising  as  complications,  of  which  septic  poisoning 
would  be  an  example. 

Simple  fractures  of  the  lower  jaw  unite  in  from  four  to  six  weeks. 
Compound,  multiple,  and  comminuted  fractures  are  often  retarded 
considerably  beyond  this  period,  two  to  three  months  not  infrequently 
being  required  for  a  good  union  to  be  formed. 

The  callus  formed  about  the  fractured  ends  of  the  bone  fre- 
quently causes  considerable  deformity;  this,  however,  is  only  tempo- 
rary, for  it  is  eventually  removed  by  absorption,  and  the  contour  of 
the  face  is  restored  to  its  orisfinal  lines. 


CHAPTER    XXII. 
FRACTURES   OF  THE  INFERIOR  MAXILLA   (Continued). 

Treatment. 

Two  conditions  are  absolutely  necessary  to  the  successful  treat- 
,ment  of  fractures,  no  matter  where  located: 

First.  Accurate  adjustment  of  the  fractured  portions  of  the 
bone. 

Second.     Complete  immobility  of  the  parts  until  union  has  taken 

place. 

FiG.  75. 


Four-tailed  Bandage  for  Fracture  of  the  Lower  Jaw.     (After  Heath.) 

Various  methods  and  appliances  have  been  introduced  for  the 
purpose  of  fixation  of  fractures  in  the  lower  jaw,  from  the  simple  four- 
tailed  bandage  to  the  most  elaborate  interdental  splint.  The  particular 
method  to  be  adopted  in  each  individual  case  must  be  determined  by 
the  location  and  extent  of  the  fracture,  and  the  complications  attending 
it.  Fractures  complicated  with  laceration  of  the  soft  tissues,  or  with 
hemorrhage,  must  be  treated  upon  the  common  ground  of  wounds  in 
general,  viz:  to  arrest  the  hemorrhage,  render  the  wound  aseptic,  and 
close  the  soft  tissues;  after  which  the  fracture  may  be  reduced  and  the 
208 


FRACTURES   OF   THE    INFERIOR    MAXILLA. 


209 


appliance  adjusted  which  has  been  selected  tQ  maintain  the  immobility 
of  the  parts. 

Simple  fractures,  with  only  slight  displacement,  may  be  reduced 
and  usually  maintained  in  position  by  a  simple  four-tailed  bandage 
(Fig.  75),  or  the  Barton  or  Hamilton  bandages  (Figs.  76,  yy),  some- 

FiG.  76. 


Garretson's  Modification  of  the  Barton  Bandage.     (After  Garretson.) 

Fig.  77. 


Hamilton  Bandage  for  Fracture  of  the  Lower  Jaw.     (After  Hamilton.) 

times  combined  with  an  external  splint  molded  to  the  chin;  or  wires 
may  be  twisted  around  the  firm  teeth  upon  either  side  of  the  fracture 
(Fig.  78),  the  wires  to  be  passed  through  the  approximal  spaces  at  the 
margin  of  the  gums;  but,  better  still,  the  Angle  fracture  bands  and 
screws  or  wire. 

The  Angle  appliance  consists  of  platinum  or  German  silver  bands,. 

15 


2IO 


SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS, 


which  pass  around  the  teeth  in  the  form  of  a  loop  and  are  retained  in 
position  by  means  of  a  set-screw,  which  passes  through  the  tubes 
soldered  to  the  ends  of  the  band,  and  which  are  drawn  together  by  the 
screw  until  it  securely  grips  the  tooth  (Fig.  79). 

One  of  these  bands  is  fastened  to  a  firm  tooth  on  either  side  of  the 
fracture;  a  screw  is  then  passed  through  tubes  prepared  for  its  recep- 
tion upon  the  side  of  each  band,  and  the  fracture  approximated  and 
maintained  in  position  by  tightening  the  screw  (Fig.  80). 


Method  of  Holding  Detached  Pieces  of  the  Ramus  in  Apposition  with  other  Frag- 
ments OF  the  Jaw.     (After  Vinke.) 

Fig.  79. 


Angle  Apparatus  Applied. 


Another  method  is  to  solder  small  metallic  buttons  upon  the  side 
of  the  bands,  and  approximate  the  fractured  ends  of  the  bone  by  pass- 
ing binding  wire  around  the  buttons  in  the  form  of  the  figure  8  (Fig, 
81). 

This  method  is  applied  to  single  fractures  in  all  locations  of  the 
jaw,  but  in  comminuted  or  multiple  fractures,  where  the  displacement 
is  considerable,  and  difficult  of  reduction,  there  is  constant  danger  of 
displacement,  while  the  strain  upon  the  teeth  to  which  the  bands  are 


FRACTURES    OF   THE    INFERIOR    MAXILLA.  211 

fastened  soon  loosens  them  in  their  alveoli,  and  they  become  worthless 
as  points  of  anchorage. 

In  those  cases  where  the  teeth  have  been  loosened  or  dislodged, 
or  the  jaw  is  edentulous,  the  above  method  of  wiring  and  the  Angle 
appliance  cannot  be  used.  Drilling  the  maxillary  bone  and  wiring  the 
fractured  ends  together  is  the  best  method  in  these  cases.  Wiring  the 
fractured  jaw  at  any  point  anterior  to  the  first  molar  can  be  accom- 
plished inside  of  the  mouth,  but  in  locations  posterior  to  this,  or  in  the 
ascending  ramus,  it  becomes  necessary  to  operate  from  the  outside,  by 
laying  open  the  external  tissues. 

Two  considerations,  however,  should  be  constantly  borne  in  mind 
in  all  operations  on  the  jaws: 

First.  To  avoid  any  cutting  operations  upon  the  external  tis- 
sues of  the  face,  if  the  operation  can  be  done  through  the  mouth,  that 
there  may  be  no  disfiguring  scar  left  behind. 

Fig.  8i. 


SHSi^H^^^^^^^^,^ 


Angle  Apparatus,  showing  Adjustment.     (After  Angle.) 

Second.  If  it  becomes  necessary — and  this  often  occurs — to  op- 
erate through  incisions  in  the  external  tissues,  care  should  be  taken 
that  the  lines  of  incision  follow  the  natural  lines  of  the  face,  and  when 
operating  upon  the  lower  maxilla  to,  as  far  as  possible,  keep  the  line  of 
incision  under  the  lower  border  of  the  jaw,  for  the  same  reason. 

In  wiring  a  fracture  of  the  lower  maxilla  through  the  mouth,  the 
lip  or  cheek  should  be  dissected  from  the  bone  at  the  point  of  fracture 
to  a  depth  that  will  permit  of  the  passage  of  a  drill  between  the  roots  of 
the  adjacent  teeth  without  injuring  them.  The  size  of  the  drill  should 
be  three-thirty-seconds  to  one-eighth  of  an  inch  in  diameter.  Holes 
should  be  drilled  through  the  bone,  one  upon  each  side  of  the  frac- 
ture, between  the  roots  of  the  teeth,  at  points  sufficiently  remote  to 
insure  solid  osseous  structure.  A  single  or  double  silver  wire,  or 
silver-plated  copper  wire,  is  then  passed  through  the  hole  upon  one 
side,  back  through  the  hole  upon  the  opposite  side,  the  ends  brought 
together,  and  twisted  until  the  fractured  ends  of  the  bone  are  approxi- 


212 


SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 


mated.     The  wire  is  then  cut  at  a  Httle  distance  from  the  jaw,  and  bent 
down,  or  turned  in  between  the  teeth. 

Another  method  of  securing  the  ends  of  the  wire  is  by  twisting 
each  end  separately  in  the  form  of  a  spiral,  as  practiced  by  Thomas,  of 
Liverpool,  England  (Fig.  82). 

Fig.  82. 


Thomas's  Method  of  Wiring  Median  Fracture  of  the  Lower  Jaw.     (After  Erichsen.) 

Fig.  83. 


Tho.mas's  Method  of  Wiring  Fracture  of  the  Lower  Jaw.     (After  Erichsen.) 

Fig.  83  illustrates  a  method  of  wire  suturing  in  cases  where  the 
fracture  is  anterior  to  the  third  molar  and  posterior  to  the  bicuspids, 
by  passing  the  suture  around  a  molar  tooth  and  then  through  the  jaw 
at  some  point  at  the  anterior  side  of  the  fracture. 

The  writer  has  adopted  a  method  which  he  likes  better  than  either 
of  these,  viz:  that  of  passing  the  ends  of  the  wire  through  lead  buttons, 
and,  where  the  dangers  of  displacement  are  considerable,  using  a  lead 
clamp  which  reaches  across  the  fracture,  having  two  holes  in  the  ends 
to  correspond  with  the  holes  which  have  been  drilled  in  the  jaw.  The 
wire  is  first  passed  through  the  holes  in  one  end  of  the  clamp,  then 


FRACTURES    OF    THE    INFERIOR    MAXILLA.  213 

through  the  jaw  on  one  side,  back  through  the  other,  through  the 
holes  in  the  opposite  end  of  the  clamp,  and  the  free  ends  of  the  wire 
twisted  until  the  fracture  is  brought  into  position.  He  has  also  found 
it  to  be  an  advantage,  in  those  cases  presenting  considerable  displace- 
ment with  a  tendency  of  the  fractured  ends  of  the  bone  to  slide  upon 
each  other  and  thus  prevent  a  perfect  occlusion  of  the  teeth,  to  insert 
izi'o  wire  sutures  about  half  an  inch  apart,  one  as  near  the  lower  border 
of  the  jaw  as  possible  without  impinging  upon  the  contents  of  the 
inferior  dental  canal,  and  the  other  through  the  alveolar  process. 

When  the  operation  is  made  through  the  external  tissues  of  the 
face,  it  is  better  to  twist  the  wires,  cutting  them  as  short  as  possible. 

Fig.  84. 


Hammond  Wire  Splint.     (After  Heath.) 

without  endangering  their  strength,  turn  the  points  down,  and  after 
thorough  irrigation  with  antiseptic  solutions,  to  close  the  wound 
except  at  the  point  directly  over  the  ends  of  the  wire,  treating  it  anti- 
septically.     The  wires  may  be  removed  in  from  four  to  six  weeks. 

Hammond's  wire  splint  is  a  very  useful  appliance,  exceedingly 
effective  and  simple  to  construct  (Fig.  84).  An  impression  of  the 
jaw  is  taken,  and  a  cast  made  from  this.  Upon  the  cast  a  strong  iron 
or  German-silver  wire  is  fitted,  following  the  outlines  of  the  teeth,  at 
the  margin  of  the  gums,  upon  the  lingual  and  buccal  surfaces,  and  the 
ends  soldered  or  brazed.  This  is  then  slipped  over  the  teeth,  being 
held  in  position  by  means  of  fine  wire  carried  between  the  teeth,  and 
over  the  splint  (see  Fig.  85).  To  prevent  the  iron  wire  from  rusting, 
the  appliance  should  be  tinned;  the  German-silver  appliance  can  be 
plated  with  gold. 


214 


SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 


The  Shotwell  fracture  clamp  is  an  ingenious  adaptation  of  the 
principle  of  the  rubber-dam  clamp  to  the  treatment  of  fractures  of  the 
jaws  (Fig.  86).  It  is  susceptible  of  being  applied  to  all  forms  of  frac- 
tures situated  in  front  of  the  angle.  This  clamp  may  be  made  of  steel 
or  German  silver. 

Fig.  8s. 


Hammond  Wire  Splint.     (After  Heath.) 

Fig.  86. 


Shotwell  Fracture  Clamp. 

Various  forms  of  interdental  splints  have  been  devised,  and  made 
of  many  materials, — gutta-percha,  vulcanite,  and  the  various  metals; 
the  principal  feature  of  all  being  that  they  were  molded  to  fit  the 
teeth,  and  extended  to  some  distance  upon  each  side  of  the  fracture. 
They  are  either  intended  to  act  as  an  internal  support  while  the  jaw  is 


FRACTURES    OF    THE    INFERIOR    MAXILLA.  21 5 

firmly  held  against  the  upper  teeth,  or  they  are  secured  to  the  teeth  or 
bone  by  screws  or  metal  wire,  or  by  external  supports  in  the  form  of 
rods  fastened  to  the  side  of  the  splint,  and  coming  out  at  the  angles  of 
the  mouth. 

Gunning,  Hayward,  Kingsley,  Bean,  Moore,  Lonsdale,  and  Hill 
have  each  devised  interdental  splints,  having  attachments  for  outside 
supports. 

The  Kingsley  splint  is  the  one  most  commonly  used,  and  the  de- 
scription of  it  will  be  given  in  Dr.  Kingsley's  own  words : 

"Restore  to  position  displaced  fragments,  as  far  as  can  be  done 
without  much  effort,  the  only  object  being  that  it  makes  it  a  little  easier 
to  take  an  impression.  I  have  always  used  plaster  for  such  an  impres- 
sion, and  see  no  reason  for  using  any  other  substance,  and,  indeed, 
know  of  no  other  substance  as  good. 

"The  impression  of  the  deranged  fragments  may  be  taken  as  a 
whole  in  an  impression-cup,  or,  if  convenient  to  do  so,  it  can  be  taken 
in  sections  without  any  cup.  Either  course,  in  my  practice,  has  an- 
swered equally  well.  The  only  object  is  to  obtain  casts  of  all  the 
fragments,  either  together  or  separately.  Take  also  an  impression  in 
plaster  of  the  upper  jaw,  and  make  a  cast  from  it.  No  dentist  should 
be  at  all  in  doubt  as  to  the  relation  which  the  fragments  of  the  lower 
jaw  should  hold  to  the  upper." 

The  cast  of  the  lower  jaw  must  be  separated  with  a  saw  upon  the 
line  of  the  fractures,  and  the  pieces  readjusted  by  using  the  cast  of  the 
upper  jaw  as  a  guide. 

He  further  says,  "There  are  invariably,  even  if  there  are  but  few 
teeth  in  the  mouth,  certain  marks  of  abrasion  on  the  antagonizing 
surfaces  which  identify  with  exactness  the  position  which  the  frag- 
ment formerly  sustained  to  the  upper  jaw,  and  like  means  of  identifica- 
tion I  have  never  failed  to  find,  even  in  the  rnouths  of  children,  when 
they  were  shedding  and  erupting  teeth;  therefore,  there  is  no  excuse 
for  failing  to  reconstruct  the  model  of  the  lower  jaw,  and  make  it  iden- 
tical with  the  original  in  its  normal  condition. 

"Upon  such  a  model  the  construction  of  a  splint  of  vulcanite  in- 
volves no  manipulations  which  are  not  common.  Sheet  wax,  a  single 
line  in  thickness,  carefully  pressed  over  the  teeth,  and  to  a  little  extent 
encroaching  on  the  gums,  gives  the  form  required.  If  the  fracture  is 
in  front,  the  splint  need  not  cover  all  the  back  teeth ;  but  if  it  be  at  the 
sides,  it  is  better  to  cover  all  the  teeth  of  that  side.  It  is  also  better  to 
set  the  casts  of  the  upper  and  lower  jaws  in  an  articulator,  and  thus 
make  prints  of  the  upper  teeth  in  the  wax,  to  be  retained  in  the  splint. 

"One  of  the  easiest  things  of  which  to  make  the  arms  is  a  couple 
of  discarded  excavators,  flattening  the  ends  which  are  to  be  imbedded, 
and  curving  them  with  much  care  around  the  corners  of  the  mouth; 


2i6 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


they  should  terminate  at  the  angle  of  the  jaw.  The  flattened  ends 
should  be  made  quite  broad,  and  thoroughly  imbedded  in  the  splint,  as 
much  strain  comes  upon  them." 

Figs.  87  and  88  show  a  device  of  the  writer's  which  he  has  found 
to  simplify  the  making  and  adjusting  of  the  splint.  It  obviates  the 
necessity  of  a  specially  prepared  flask  or  an  extra  large  vulcanizer  in 
which  to  vulcanize  the  splint.  The  arms  are  provided  with  separable 
sockets  or  mortises.  The  sockets  are  imbedded  in  the  sides  of  the  wax 
form  of  the  splint,  which  will  then  enter  any  ordinary  sized  flask. 
After  the  splint  is  finished,  the  tenon  of  the  arm  slips  tightly  into  the 
socket  or  mortise. 

Fig.  87. 


Author's  Arm  and  Socket  (one  side)  for  Kingsley  Splint. 


Fig. 


Author's  Socket  for  Kingsley  Splint  in  position  for  attachment  of  the  arm. 


"The  subsequent  steps  are  familiar  to  every  dentist,  viz :  investing, 
packing,  vulcanizing,  and  finishing.  In  finishing,  it  is  better  to  enlarge 
the  sockets  for  the  teeth  a  little,  so  that  there  will  be  no  impinging  upon 
the  crowns  when  the  splint  is  introduced,  and  also  to  make  openings 
through  the  top  or  side,  against  each  tooth  adjoining  the  fracture,  so 
that  it  can  be  determined  when  the  fragments  are  fully  in  their  place 
(Fig.  89).  The  latter  holes  will  be  convenient  to  use  in  cleansing  the 
apparatus  by  inserting  in  them  the  nozzle  of  a  syringe.  If  the  splint  is 
properly  made,  the  teeth  of  each  fragment  will  follow  into  the  indenta- 
tions prepared  for  them,  without  severe  pressure ;  if  they  do  not,  it  is 
quite  as  well  to  bind  the  splint  in  position,  and  wait  events.     It  will 


FRACTURES    OF    THE    INFERIOR    MAXILLA. 


217 


probably  be  found,  a  few  hours  later,  that  they  have  gained  their  place 
without  further  aid." 

The  splint  is  retained  in  position  by  passing  a  narrow  bandage 
over  the  arm  of  the  splint  and  under  the  chin,  back  and  forth,  until  it  is 
firmly  fixed  (Fig.  90).  The  after-treatment  is  that  of  wounds  of  the 
mouth  in  general. 


Kingsley's  Interdental  Splint.     (Alter  Kingsley 


Fig.  90. 


Kingsley's  Interdental  Splint  Applied.     (After  Kingsley.) 


The  ordinary  duct-compressor  may  be  utilized  for  the  same  pur- 
pose by  attaching  the  splint  to  the  upper  arm  of  the  compressor 
(Fig.  91),  and  securing  it  in  place  by  the  ratchet  device  for  causing 
compression.    Fig.  92  shows  splint  in  position. 

Another  admirable  method  of  securing  the  ordinary  interdental 
splint  in  position  is  by  the  use  of  oxyphosphate  of  zinc  cement.  The 
writer  has  used  this  method  many  times  during  the  past  twelve  years— 
in  cases  where  there  was  moderate  displacement— to  his  entire  satisfac- 


2l8 


SURGERY    OF    THE    FACE,    MOUTH,    AND   JAWS. 


tion  (Fig.  93).  The  cement  should  be  mixed  a  little  thicker  than 
cream,  and  the  sockets  in  the  splints  for  the  reception  of  the  crowns  of 
the  teeth  lined  with  it.  The  teeth  must  be  thoroughly  cleansed  before- 
hand; then  dry  the  surface  with  bibulous  paper,  and  press  the  splint 
into  place  with  the  thumb  and  fingers,  holding  it  in  that  position  until 

Fig.  qt. 


Interdental  Splint  attached  to  Duct  Depressor.     (After  Kingsley.) 

Fig.  92. 


Sa.me  in  Position.     (After  Kingsley.) 

the  cement  has  set.  To  insure  adhesion  of  this  cement,  the  apparatus 
must  be  kept  free  from  moisture  while  the  cement  is  setting.  This  may 
be  accomplished  with  bibulous  paper  or  napkins  and  the  saliva  ejector. 
This  method,  which  was  first  suggested  by  Heath,  who  used  gutta- 
percha instead  of  the  oxyphosphate  cement,  is  certainly  preferable  to 
the  use  of  retaining  screws  or  wires. 


FRACTURES    OF    THE    INFERIOR    MAXILLA. 


219 


The  Kingsley  splint  may  be  made  of  cast  metal, — tin  or  Weston's 
metal, — or  of  silver  swaged  over  metal  dies,  or  by  the  electro-deposit 
method.  The  latter  method  gives  the  best  adaptation,  but  has  the  dis- 
advantage of  requiring  a  longer  time  for  its  construction.  It  has, 
however,  in  the  practice  of  the  writer,  given  the  utmost  satisfaction. 

In  the  selection  of  the  particular  method  that  shall  be  employed  in 
the  treatment  of  fractures  of  the  body  of  the  jaw,  that  one  should  be 
chosen  which  will  be  most  likely  to  secure  absolute  immobility  of  the 
fracture,  and  at  the  same  time  give  free  use  of  the  jaw.  The  Kingsley 
interdental  splint,  the  Angle  apparatus,  and  the  bone-wiring  operation 
will  all  give  these  results  in  individual  cases. 

Fig.  93. 


Interdental  Metal  Splint  Cemented  into  Position. 


In  charity  work,  the  latter  operation  is  generally  chosen  as  least 
expensive  in  the  consumption  of  time  and  money.  It  has  the  disad- 
vantage, however,  of  rendering  a  simple  fracture  a  compound  one; 
but  simple  fractures  are  not  often  found  among  hospital  cases,  as 
nearly  all  of  them  are  the  result  of  severe  injuries,  and  consequently  are 
usually  compound  fractures.  It  has  been  the  fortune  of  the  writer 
many  times  to  treat  this  class  of  injury  by  wiring  the  bone,  and  experi- 
ence teaches,  taking  all  things  into  consideration,  that  it  is  the  most 
satisfactory  method. 

The  hygienic  conditions  of  the  mouth  are  important  factors  in  the 
treatment  of  fractures  of  the  jaw,  and  that  method  will  be  most  success- 
ful, other  things  being  equal,  w-hich  will  permit  of  the  most  perfect 
cleansing  of  the  mouth  without  disturbing  the  appliance. 

Interdental  splints  are  of  no  value  in  the  treatment  of  fractures  of 
the  angle,  ramus,  coronoid  or  condyloid  processes,  if  uncomplicated 


220 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


with  fractures  of  the  body  of  the  bone.  In  such  cases  the  various 
forms  of  bandages,  wiring  the  upper  and  lower  teeth  together  after  the 
suggestion  of  Heath,  or  the  Angle  appliance,  are  the  best  means  of 
treatment.  By  the  Angle  method  the  jaws  would  be  firmly  bound  to- 
gether by  applying  bands  to  the  upper  and  lower  teeth  at  points  oppo- 

FiG.  94. 


Angle's  Appliance  for  Fracture  through  the  Angle.     (After  Angle.) 

Fig.  95. 


Angle's  Appliance  for  Fracture  through  the  Angle  and  Cuspid  Region.    (After  Angle.) 

site  to  each  other,  and  the  use  of  the  wire  ligature  in  the  form  of  a 
figure  8,  as  described  before  in  the  treatment  of  simple  fractures. 
Figs.  94,  95,  96,  illustrate  the  Angle  method  applied  to  this  class  of 
cases. 

Occasionally  the  surgeon  will  be  called  upon  to  treat  a  fracture  of 
the  lower  jaw  in  which  all  the  known  methods  of  retaining  the  frac- 


FRACTURES    OF    THE    INFERIOR    MAXILLA. 


221 


tured  bones  in  their  proper  apposition  will  fail,  or  in  which  an  appli- 
ance must  be  devised  upon  short  notice  which  will  be  applicable  to  the 
peculiar  conditions  existing  in  an  individual  case.  As  an  illustration, 
a  case  in  point  will  be  briefly  described.  Mr.  G.  G.,  a  furnace  man,  em- 
ployed at  the  Iroquois  Furnace  Company,  South  Chicago,  was  blown, 
by  the  bursting  of  the  furnace  door,  twenty-six  yards,  striking  broad- 
side against  a  wall.  His  face  and  head  especially  seemed  to  receive  the 
force  of  the  concussion.  The  lower  jaw  was  fractured  upon  the  right 
side,  just  anterior  to  the  angle,  and  between  the  cuspid  and  first  bi- 
cuspid teeth.  There  was  considerable  displacement  on  account  of  the 
location  of  the  fractures  and  the  contraction  of  the  muscles,  the  middle 
fragment  overriding  the  others  upon  the  outside.     For  several  days 

Fig.  96. 


Angle's  Appliance  bor  Fracture  through  Both  Angles.    (After  Angle.) 


reduction  was  not  attempted,  as  the  man  was  suffering  from  a  severe 
concussion  of  the  brain,  and  gave  little  hope  of  recovery.  Four  days 
after  his  admission,  the  brain  symptoms  having  somewhat  improved,  a 
careful  examination,  under  ether,  was  instituted.  Efforts  were  made  to 
replace  and  secure  the  middle  fragment  in  its  normal  position  by  the 
various  methods  of  external  splints,  bandages,  and  wiring  of  the  teeth, 
but  without  avail.  An  interdental  splint  could  have  been  made  for  the 
case  if  the  patient  had  been  sufficiently  recovered  from  the  injury  to  the 
head  to  exercise  self-control.  This  being  out  of  the  question,  it  there- 
fore became  necessary  to  devise  some  other  means  of  maintaining  the 
fractured  bone  in  normal  position.  This  was  accomplished  by  making 
two  incisions  in  the  soft  tissues  down  to  the  bone,  one  just  behind  the 
angle  of  the  jaw,  about  half  an  inch  above  the  lower  border,  and  the 
other  between  the  roots  of  the  cuspid  and  lateral  incisor  teeth,  at  about 
the  same  distance  above  the  lower  border  of  the  jaw.  Holes  were  then 
drilled  in  the  bone  at  the  points  of  incision,  and  long  nickel-plated  pic- 


222  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

ture  screws  set  into  the  holes.  Extension  was  then  made  upon  the  an- 
terior fragment,  aided  by  ligatures  passed  around  the  incisor  teeth,  until 
the  middle  fragment  could  be  forced  into  place.  Extension  was  main- 
tained by  placing  a  wooden  brace,  made  from  the  side  of  a  cigar-box, 
between  the  screws.  Ligatures  were  then  passed  from  screw  to  screw, 
and  under  the  ends  of  the  brace,  in  the  form  of  the  figure  8,  thus 
making  a  rigid  appliance,  which  held  the  fractures  immovably  in  their 
normal  position.  Dressings  were  applied  to  the  external  wounds,  and 
the  mouth  kept  as  clean  as  the  circumstances  would  permit.  Four 
weeks  later  the  screws  were  removed,  and  union  was  found  to  have 
taken  place,  while  the  perfect  occlusion  of  the  teeth  proved  that  the 
fractured  bones  had  been  placed  in  normal  apposition. 

Fractures  of  the  alveolar  process  following  the  extraction  of  teeth 
need  no  other  treatment,  as  a  rule,  than  forcing  the  separated  parts 
into  position  with  the  thumb  and  fingers. 

The  after-treatment  is  comprehended  in  the  term  "surgical  clean- 
liness." 

Abscess  of  the  Jaws. — Abscess  of  the  jaws  frequently  follows  com- 
pound fractures.  This  is  the  result  of  local  infection,  generally  from  a 
filthy  condition  of  the  oral  cavity  or  from  necrosed  bone. 

It  is.  often  stated  by  the  opponents  of  the  germ  theory  of  disease 
that  pathogenic  micro-organisms  are  constantly  found  in  the  blood  and 
tissues  of  healthy  individuals.  This  statement  has  not  been  substan- 
tiated, either  by  the  most  careful  microscopic  research  or  by  clinical 
observation.  There  is  no  doubt  whatever  that  such  organisms  do 
sometimes  gain  access  to  the  tissues  of  the  healthy  living  body,  but 
they  are  at  once,  and  almost  invariably,  destroyed  by  the  action  of  the 
living  cells  and  fluids  of  the  body,  or  are  eliminated  by  the  excretory 
organs. 

A  simple  fracture  will  heal  without  suppuration  in  a  healthy  indi- 
vidual, even  though  it  had  been  demonstrated  that  micro-organisms 
were  already  in  the  blood;  but  if  a  certain  quantity  of  the  pus- 
producing  microbes  were  introduced,  sufificient  to  overcome  the  resist- 
ance of  the  tissues  and  fluids  of  the  body,  suppuration  was  the  result. 
Vital  resistance,  therefore,  plays  an  important  part  in  preventing 
suppuration. 

As  soon  as  fluctuation  can  be  detected,  the  abscess  should  be 
opened,  preferably  through  the  mouth,  so  as  to  avoid  a  scar;  but  some- 
times it  is  necessary  to  open  it  through  the  external  tissues,  especially 
where  there  is  a  tendency  to  phlegmonous  inflammation  in  the  sub- 
maxillary region  and  the  neck.  After  the  pus  has  been  evacuated, 
search  should  be  made  for  necrosed  bone,  and  if  found,  it  should  be 
immediately  removed,  provided  separation  has  taken  place,  and  the 
wound  irrigated  and  dressed  antiseptically.     If  separation  of  the  dead 


FRACTURES    OF    THE    INFERIOR    MAXILLA.  223 

bone  from  the  living  has  not  taken  place,  it  is  better  to  wait  for  nature 
to  complete  the  process,  as  surgical  interference  under  such  circum- 
stances is  not  indicated. 

Preceding-  the  discovery  of  an  abscess,  there  will  always  be  an 
elevation  of  the  body  temperature  from  2°  to  6°  or  7°  Fahrenheit,  which 
is  always  indicative  of  the  formation  of  pus,  and  the  presence  in  the 
circulation  of  septic  ptomaines.  Such  a  condition  should  at  once  lead 
to  a  critical  examination  of  the  wound  and  the  surrounding  tissues. 
If  septicemia  should  develop,  treat  the  case  as  indicated  in  a  previous 
chapter  upon  Septicemia. 


CHAPTER    XXIII. 

FRACTURES  OF  THE  SUPERIOR  MAXILLA  AND  UPPER  BONES 

OF  THE  FACE. 

Fractures  of  the  superior  maxillary  bones  are,  from  their  pro- 
tected location,  quite  rarely  met  with  except  in  the  alveolar  process. 
The  causes  of  such  injuries  in  this  location  are  usually  the  extraction  of 
teeth  or  blows  or  falls  upon  the  chin,  which  separate  and  split  open 
the  walls  of  the  alveoli.  This  is  accomplished  in  the  one  case  by  the 
lateral  force  applied  breaking  up  the  attachments  of  the  roots  of  the 
teeth,  and  in  the  other  by  driving  the  teeth  upward  and  through  their 
alveoli. 

Such  injuries,  however,  are  never  very  serious,  and  rarely  require 
special  apparatus  to  maintain  the  fractured  bones  in  their  normal  posi- 
tion. 

Injuries  of  the  upper  bones  of  the  face,  which  cause  comminuted 
fractures  and  separation  from  the  bones  of  the  cranium,  are  always 
the  result  of  great  violence, — like  the  passage  of  the  wheel  of  a  car- 
riage over  the  face,  falling  from  a  great  height,  the  kick  of  a  horse, 
a  blow  in  the  face  by  some  heavy  missile  thrown  with  great  force, 
a  gunshot  wound,  the  overturning  of  a  carriage  upon  the  occupant, 
crushing  of  the  head  between  a  moving  elevator  and  the  floor,  or  other 
heavy,  crushing  force. 

Since  the  general  introduction  of  passenger  and  freight  elevators 
into  hotels,  ofHce  buildings,  and  large  manufacturing  establishments, 
"elevator"  accidents  are  much  more  likely  to  occur,  and  will  doubtless 
be  found  more  and  more  common.  The  experience  of  the  writer,  at 
least,  leads  to  this  conclusion,  for  during  the  last  fifteen  years  about 
twenty-five  per  cent,  of  all  the  cases  of  fracture  of  the  upper  bones  of 
the  face  which  have  come  under  his  care  have  been  caused  by  this  class 
of  accidents. 

The  class  of  injuries  which  forms  the  subject  of  the  present  chap- 
ter is  one  which  has  received  but  little  attention  from  either  the  gen- 
eral surgeon  or  the  oral  specialist.  Several  of  the  leading  works  on 
surgery  make  no  mention  whatever  of  them,  which  is  due  no  doubt  to 
the  fact  that  the  accidents  which  cause  them  have  been  in  the  past  of 
rare  occurrence. 

224 


FRACTUKi:S    OF    THE    SUPERIOR    MAXILL.E,    ETC.  225 

During  the  lust  few  \cars  five  cases  have  come  under  the  personal 
care  of  the  writer  at  St.  Luke's  Hospital.  Tlie  first  led  to  a  somewhat 
careful  examination  of  the  text-books  and  periodical  literature  bearing 
upon  the  subject.  So  far  he  has  been  able  to  gather  together  but  nine- 
teen cases  which  can  be  fairly  classed  as  similar  to  those  which  form 
the  subject  of  this  chapter. 

These  injuries  are  always  serious,  and  often  prove  fatal,  either 
from  shock,  hemorrhage,  direct  injury  to  the  l)rain,  or  from  secondary- 
complication. 

In  those  cases  which  survive  the  shock  of  injury  and  escape  im- 
mediately serious  complications  of  the  brain,  a  favorable  termination 
may  be  looked  for,  and  in  many  cases,  if  properly  treated,  with  very 
little  deformity.  This,  however,  will  depend  very  much  upon  the 
character  and  location  of  the  particular  injury,  and  the  success  ob- 
tained in  readjusting  the  fractured  and  dislocated  bones,  and  main- 
taining them  in  their  proper  positions. 

For  the  purpose  of  reference,  the  various  published  cases  are  here 
grouped  together,  only  brief  mention  being  made  of  the  extent  of  the 
injury  and  the  percentage  of  mortality. 

In  speaking  of  this  class  of  injuries,  Erichsen  says,  "In  some  cases 
all  the  bones  of  the  face  appear  to  have  been  smashed  and  separated 
from  the  skull  by  the  infliction  of  great  violence."  He  mentions  four 
cases  of  this  form  of  injury,— one  reported  by  South,  one  by  Vidal^, 
and  two  which  came  under  his  own  notice. 

The  injury  in  South's  case  was  caused  by  a  man  being  "struck 
in  the  face  by  the  handle  of  a  rapidly  revolving  crank."  All  the  bones 
of  the  face  were  "separated  and  loosened,"  and  so  comminuted  as  ta 
feel  "like  beans  in  a  bag." 

Vidal's  case,  also  a  man,  was  injured  by  a  "fall  from  a  building: 
and  striking  upon  the  face,  which  fractured  and  separated  all  the  facial 
bones." 

Erichsen's  cases  were  both  the  result  of  falls  from  a  considerable 
elevation,  and  striking  upon  the  face.  The  two  former  recovered; 
the  two  latter  died  in  a  few  hours. 

Packard  mentions  three  cases,  one  by  Cotting,  in  which  the  face 
was  crushed  by  a  cart-wheel  passing  over  it;  another,  brought  to  the 
Pennsylvania  Hospital,  in  which  the  injury  was  received  by  the  head 
being  caught  between  the  platform  of  a  steam  hoisting  machine  and 
the  floor;  the  third,  a  case  reported  by  Heath  in  his  "Injuries  and  Dis- 
eases of  the  Jaws,"  which  was  under  the  care  of  Dr.  Fyfife.  The  first 
and  last  cases  recovered;  in  the  other,  death  resulted  in  a  few  hours. 

Heath  describes  two  cases.  The  first  came  under  his  personal 
notice,  and  was  "caused  by  the  passage  of  a  wagon-wheel  over  the 
face.     The  bones  were  completely  crushed  and  separated  one  from 

16  . 


226  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

another,  and  death  was  instantaneous."  The  second  one  is  that  re- 
ported by  Dr.  F}ffe,  the  same  before  referred  to  as  mentioned  by 
Packard,  and  which  will  be  described  later. 

Tiffany  mentions  a  single  case,  which  was  reported  by  Professor 
Christopher  Johnston.  The  patient,  a  man,  was  struck  in  the  face  by 
the  walking  beam  of  a  steamboat.  All  the  bones  of  the  face  were 
crushed,  and  "seemed  literally  to  consist  of  a  bag  of  bones,  moving 
freely  with  inspiration  and  expiration,  so  extensive  was  the  comminu- 
tion." This  case  made  a  good  recovery,  and  an  excellent  result  was 
obtained  by  supporting  the  superior  maxillae  by  means  of  a  silver 
wire  passed  through  the  cheeks  and  under  the  teeth,  and  uniting  the 
ends  of  the  wire  over  tile  head  by  a  rubber  band. 

Richard  Wiseman  published  the  report  of  the  first  case  on  record, 
and  described  the  method  of  treatment.  The  patient  was  a  little  boy, 
eight  years  of  age,  who  was  kicked  by  a  horse,  the  whole  upper  jaw 
being  driven  in  so  that  the  finger  could  not  be  passed  behind  the 
palate.  A  flattened  hook  was  constructed  which  could  be  inserted  be- 
hind the  palate,  and  by  extension,  constantly  maintained  by  the 
patient  and  assistants,  the  bones  were  held  in  place  and  a  good  recov- 
ery followed. 

In  the  case  reported  by  Dr.  Fyffe,  of  Vvestminster  Hospital,  Lon- 
don, the  patient  was  thrown  from  a  cab,  the  vehicle  turning  over  upon 
him.  The  superior  and  inferior  maxillae  were  fractured,  and  the  bones 
of  the  face  detached  from  the  skull,  so  that  the  former  "moved  up 
and  down  in  the  act  of  swallowing,"    This  patient  also  recovered. 

Holmes  describes  a  single  case,  in  which  the  bones  of  the  face 
were  crushed  and  dislocated  by  a  carriage-wheel  passing  over  the 
face,  and  in  which,  after  recovery,  there  "was  a  disagreeable  lengthen- 
ing of  the  face,"  as  the  result  of  the  injury.  It  would  seem  more 
likely,  however^  that  this  condition  was  the  result  of  the  treatment. 
Among  the  methods  of  treatment  suggested  by  Holmes  are  gutta- 
percha molds,  cork  disks  placed  between  the  teeth,  wiring  of  frag- 
ments, and  carefully  adjusted  pressure  by  the  Hanesby  truss, 

Hamilton  refers  to  one  case  which  came  under  his  own  care,  in 
which  the  upper  bones  of  the  face  were  fractured  and  torn  from  their 
attachments  to  the  cranium,  and  had  to  be  supported  to  keep  them 
in  place.    The  patient  died  on  the  twelfth  day  after  the  injury. 

Mason  reports  a  case  which  was  under  the  care  of  Mr.  Bicker- 
steth,  of  Liverpool.  A  man,  standing  upon  the  deck  of  a  steamer,  was 
struck  upon  the  side  of  the  face  by  an  iron  hook  attached  to  the 
hawser,  which  had  parted  under  a  heavy  strain.  On  examination, 
"immediately  after  the  accident,  the  mouth  seemed  to  be  filled  by  a 
piece  of  bloody  meat;  but  upon  a  more  thorough  examination  this 
proved  to  be  the  muscles  attached  to  the  upper  jaw;  the  orbital  plate 


FRACTURES    OF   THE    SUPERIOR    MAXILL.E,    ETC.  22/ 

of  the  superior  maxilla  of  the  injured  side  was  found  beneath  the 
cheek,  while  the  palate  process,  with  the  alveolar  ridge  and  teeth,  were, 
for  the  time,  situated  in  the  upper  part  of  the  pharynx,  looking  to- 
ward the  bodies  of  the  upper  cervical  vertebrae.  The  facial  surface  of 
the  bone  took  the  place  of  the  roof  of  the  mouth,  jamming  the  jaws 
open.  The  soft  palate  was  not  torn,  but  considerably  injured.  The 
superior  maxilla  of  the  injured  side  was  turned  completely  upon  its 
axis.  The  detached  mass  was  replaced,  the  lower  jaw  firmly  closed 
upon  it  for  support,  and  the  whole  rapidly  united  with  scarcely  any  de- 
formity." 

Salter  reported  a  case  in  which  the  superior  maxillse  and  malar 
bones  were  separated  from  their  attachments  with  the  skull,  and  so 
crushed  as  to  feel  like  a  mass  of  "loose  bones." 

Harris,  of  New  York,  also  reported  a  case  of  a  little  child,  only 
two  years  of  age,  who  fell  a  distance  of  fifty  feet  to  the  pavement, 
striking  upon  the  face  and  sustaining  fractures  and  separation  upon 
the  median  lines  of  both  superior  maxillse  and  palate  bones.  "Union 
had  not  taken  place  six  weeks  after  the  injury." 

Houghton  describes  a  case  in  which  the  "superior  maxillse  were 
<o  fractured  and  displaced  as  to  make  it  impossible  for  the  patient  to 
protrude  the  tongue  until  after  the  bones  had  been  adjusted  to  their 
normal  position." 

Bryant  mentions  one  case  in  which  "the  superior  maxillary  bones 
were  completely  detached  from  the  skull,  and  could  be  moved  about 
in  any  direction,  yet  a  good  recovery  ensued." 

Agnew  cites  the  cases  of  AMseman,  Fyfife,  and  Packard,  but  de- 
scribes no  new  cases. 

Garretson  reports  two  cases.  The  history  of  the  first  was  fur- 
nished him  by  Professor  Agnew,  in  which  a  lad  was  crushed  between 
the  bumpers  of  two  railroad  cars,  and  sustained  diastasis  of  all  the 
bones  of  the  face  from  the  skull,  comminuted  fracture  of  the  superior 
maxilla,  and  four  fractures  of  the  inferior  maxilla.  The  patient  re- 
covered, but  with  considerable  deformity.  The  second  case,  a  painter, 
came  under  his  own  care.  The  mjury  was  caused  by  falling  from  the 
roof  of  a  house,  and  striking  upon  the  pavement  below.  He  sustained 
severe  comminuted  fractures  of  the  superior  and  inferior  maxillse,  and 
fracture  of  both  arms  and  legs.  Several  splinters  of  bone  were  removed 
from  the  anterior  portion  of  the  lower  jaw.  This  allowed  the  parts 
to  fall  together,  "the  symphysis  of  junction  being  midway  between  its 
■former  position  and  the  hyoid  bone."  The  patient  made  a  good  re- 
cover}-, but  with  considerable  deformity. 

With  this  brief  summary  of  the  history  and  results  of  the  various 
cases  found  on  record,  the  writer  will  present  those  cases  which  have 
come  under  his  own  obsers'ation  and  treatment. 


228  SURGERY    OF    THE    FACE,    MOUTH,    AND   JAWS. 

Case  No.  i.  Mr.  Conrad  A.,  Swede,  age  28  years;  occupation, 
sawyer;  employed  at  the  Pullman  Palace  Car  Works,  Pullman,  Il- 
linois; was  brought  into  St.  Luke's  Hospital  on  March  15,  1887,  in  an 
unconscious  condition,  with  an  incised  wound  of  the  right  cheek,  start- 
ing from  a  point  just  below  the  inner  canthus  of  the  eye,  and  extend- 
ing obliquely  backward  and  downward  a  distance  of  four  inches,  ex- 
posing the  superior  maxillary  bone  and  completely  penetrating  the 
cheek,  leaving  a  considerable  external  opening  into  the  mouth.  This 
wound  had  been  sewed  up  by  the  surgeon  at  the  Works.  Further 
examination  revealed  that  the  right  malar  was  crushed,  both  nasal 
bones  were  fractured  and  separated  at  the  naso-frontal  suture.  The 
left  zygomatic  process  was  fractured  near  its  union  with  the  malar 
bone,  both  superior  maxillae  were  torn  loose  from  the  bones  of  the 
cranium,  so  that  the  whole  mass  was  loose  and  freely  movable  in 
any  direction,  and  suspended  by  soft  tissues.  When  the  mouth  was 
open  to  its  fullest  extent,  the  teeth  of  the  upper  jaw  rested  upon  those 
of  the  lower.  Both  superior  maxillary  bones  were  also  fractured  on  a 
nearly  perpendicular  line,  on  the  right  side  between  the  first  and  sec- 
ond molar  teeth,  on  the  left  between  the  second  bicuspid  and  first 
molar  teeth.  Openings  existed  in  both  antra.  The  right  could  be 
entered  with  the  probe  through  the  wound  in  the  cheek,  and  also 
through  the  alveolar  process  on  the  buccal  aspect  between  the  roots 
of  the  first  and  second  molars,  while  the  left  could  be  penetrated 
through  the  buccal  surface  of  the  alveolar  process  on  the  line  of  the 
fracture  between  the  second  bicuspid  and  first  molar  teeth. 

The  palate  process  and  palate  bones  were  also  badly  crushed, 
forming  a  compound  comminuted  fracture,  with  loss  of  bone-tissue, 
leaving  an  opening  in  the  hard  palate  on  the  right  side  near  its 
posterior  edge  and  the  median  line,  through  which  the  index  finger 
could  be  freely  passed.  The  bones  of  the  internal  nose  were  badly 
comminuted,  and  several  pieces  which  were  loose  were  removed. 

The  left  side  of  the  face  was  completely  anesthetic  over  the  whole 
region  supplied  by  the  infraorbital  nerve,  while  upon  the  right  side  the 
upper  lip  and  wing  of  the  nose  only  had  lost  sensation.  The  inferior 
maxilla  was  not  injured,  and  none  of  the  teeth  had  been  lost  by  the 
injury  in  either  jaw. 

The  accident  occurred  by  the  patient  being  struck  in  the  face  by 
a  piece  of  oak  timber,  twelve  inches  in  length  and  eight  by  nine  inches 
in  diameter,  which  was  thrown  by  a  circular  saw  eighteen  inches  in 
diameter,  and  running  at  the  rate  of  about  three  thousand  revolutions 
per  minute. 

Wlien  the  patient  was  admitted  to  the  hospital,  the  chances  for 
recovery  seemed  very  small.  Cold  applications  were  ordered  over  the 
face,  and  stimulants  hypodermically,   if  the  temperature   should  fall 


FRACTURES    OF    THE    SUPERIOR    MAXILLAE,    ETC.  229 

below  normal  and  the  pulse  below  sixty;  nourishment  to  be  given  if 
possible,  and  one-fourth  of  a  grain  of  morphia  to  allay  pain,  if  found 
necessary  upon  regaining  consciousness. 

March  i6.  Swelling  of  parts  very  great;  both  eyes  closed  and 
nasal  passages  completely  plugged.  Pulse  84.  Temperature  101.8°. 
V\'ould  arouse  when  spoken  to. 

March  17.  Patient  has  rallied.  Pulse  74.  Temperature  100". 
Seems  to  be  conscious.     Swelling  less. 

On  the  i8th  his  temperature  was  normal,  and  he  rapidly  improved 
in  general  condition  from  this  date. 

The  treatment  of  the  fractured  jaws  was  begun  on  the  17th,  and 
consisted  of  first  wiring  the  posterior  fragments  of  both  superior  max- 
illae to  the  anterior  or  middle  portion,  by  means  of  silver  wire  passed 
around  the  teeth  upon  either  side  of  the  fracture.  The  fractured  palate 
bones  and  the  palate  processes  were  then  molded  into  place  as  nearly 
as  possible  by  the  fingers,  and  the  nasal  bones  lifted  into  position 
by  means  of  the  handle  of  a  small  instrument.  The  lower  jaw  was 
next  closed  upon  the  superior  teeth,  care  being  taken  to  get  a  correct 
occlusion,  and  then  held  in  position  by  means  of  an  occipito-frontal 
and  occipito-mental  bandage. 

The  following  night  the  patient  tore  off  the  bandage  several  times. 
The  nasal  passages  being  closed  from  the  results  of  the  injury,  he  had 
great  difficulty  in  breathing  when  the  jaws  were  held  tightly  together. 
The  bandages  were  therefore  reapplied  more  loosely,  but  this  allowed 
the  injured  bones  to  fall  out  of  place  and  defeat  the  object  in  view. 
The  foregoing  is  the  plan  of  treatment  usually  recommended  by  such 
authors  as  mention  this  class  of  injuries;  but  in  the  hands  of  the  writer 
it  has  proved  a  signal  failure,  from  the  fact  that  several  times  the  nose 
has  been  so  injured  and  the  parts  so  badly  swollen  as  to  close  the 
nasal  passages  for  several  days,  therefore  making  it  impossible  to 
breathe  with  any  degree  of  comfort  except  through  the  open  mouth. 

There  must  always  be  considerable  difficulty  in  any  severe  case  in 
maintaining  the  position  of  the  fractured  and  dislocated  bones  when 
this  plan  is  adopted,  and  it  is  nearly  impossible  in  those  cases  in  which 
all  the  teeth  were  lost  prior  to  the  accident,  for  it  is  a  well-known  fact 
that,  as  a  rule,  edentulous  jaws  do  not  come  in  contact,  and  if  they 
should,  a  normal  occlusion  could  not  be  obtained,  nor  the  injured  parts 
be  prevented  from  slipping  out  of  position.  The  plan  of  treatment 
adopted  by  Professor  Johnston  is  also  objectionable  by  reason  of  the 
wounds  made  in  the  cheeks. 

In  this  case  the  writer  was  compelled  to  devise  other  means, 
which  would  maintain  the  position  of  the  fractured  bones,  and  at  the 
same  time  leave  the  lower  jaw  free,  so  that  the  mouth  could  be  open 
for  the  purpose  of  breathing.    This  was  accomplished  by  adapting  the 


230  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

principle  of  the  Hayward  or  Kingsley  interdental  splint  to  the  upper 
jaw,  and  supporting  it  from  the  cranium.  Impressions  of  the  upper 
and  lower  teeth  were  taken  with  the  modeling  compound,  by  first 
molding  it  upon  the  upper  teeth,  and  while  it  was  yet  soft  forcing 
the  lower  jaw  upward  till  a  correct  occlusion  of  the  teeth  was  obtained. 
This  impression  was  trimmed  to  the  desired  shape,  a  one-eighth  inch 
steel  wire  was  imbedded  in  the  sides  upon  a  line  with  the  ends  of  the 
teeth,  then  bent  backward  upon  itself  opposite  the  cuspid  teeth,  and 
allowed  to  extend  outside  the  cheek  nearly  to  the  lower  border  of  the 
ear.  From  this  was  constructed  a  hard  rubber  splint,  with  the  wires 
attached.  The  splint  can  be  made  from  silver  swaged  over  metal  dies; 
but  if  a  metal  plate  is  desired  the  most  perfect  adaptation  can  be  se- 
cured by  the  electro-deposit  plate,  the  wires  being  attached  with 
solder.  The  splint  is  held  in  position  by  means  of  double  elastic 
straps,  attached  to  the  wire  upon  each  side,  and  buckled  to  a  close-fit- 
ting leather  or  net  cap,  which  is  reinforced  with  leather  and  laced  firmly 
upon  the  head.  This  proved  to  be  a  very  successful  appliance,  as  it 
held  the  fractured  bones  in  their  proper  position,  permitted  comfort- 
able breathing  and  free  movement  of  the  lower  jaw,  which  enabled  him 
to  talk,  and,  after  a  few  days,  to  masticate  soft  food.  Deep  indenta- 
tions were  made  in  the  under  side  of  the  splint,  in  which  the  lower  teeth 
fitted  accurately  when  the  mouth  was  closed.     (Fig.  97.) 

The  object  of  this  was  to  furnish  a  sure  guide  to  the  normal  posi- 
tion of  the  superior  maxillae.  Without  this,  the  correctness  of  the  ad- 
justment of  the  bones  could  not  have  been  verified.  Its  importance, 
therefore,  cannot  be  over-estimated.  The  only  other  treatment  was 
good  feeding,  thorough  irrigation  of  the  wound,  antrum  and  mouth, 
with  a  2  per  cent,  solution  of  carbolic  acid  every  two  or  three  hours 
imtil  the  discharges  ceased,  and  the  removal  of  a  few  spiculge  of  bone 
from  the  nose  arid  the  wall  of  the  right  antrum. 

The  patient  was  discharged  on  May  14,  with  small  fistulous  open- 
ings through  the  gums,  leading  into  both  antra  at  the  points  of  frac- 
ture, and  a  small  opening  in  the  hard  palate,  which  was  gradually 
growing  less.  There  was  also  a  slight  deflection  to  the  left  of  the  nasal 
septum,  and  a  deep  cicatrix  in  the  right  cheek  (Fig.  98).  The  opening 
into  the  right  antrum  soon  closed,  as  did  that  of  the  hard  palate. 

June  22.  The  patient  returned  for  the  removal  of  the  cicatrix  in 
the  right  cheek,  which  was  adherent  to  the  maxillary  bone. 

June  25.  Stitches  removed  and  adhesive  strips  applied,  and  the 
patient  discharged  three  days  later. 

The  opening  into  the  left  antrum  remained  patulous  for  some 
months,  with  slight  discharge  into  the  mouth,  but  finally  closed.  Sen- 
sation has  been  entirely  restored  in  both  sides  of  the  face.  The  occlu- 
sion of  the  teeth  is  nearly,  if  not  quite,  normal,  and  the  onl}'  deformity 


FRACTURES    OF   THE    SUPERIOR    MAXILL.E,    ETC. 
Fig.  97. 


231 


Case  I.    Splint  in  Position  and  supported  by  a  Leather  Cap. 


Fig.  98. 


Case  I.    After  the  Splint  was  removed. 


232 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 
Fig.  99. 


Case  I.    Before  the  Accident. 


Fig.  100. 


Case  I.    Final  Result  of  Treatment  after  Operation  upon  the  Cheek. 


FRACTURES    OF    THE    SUPERIOR    MAXILL/E,    ETC.  233 

visible  is  a  slight  flattening  of  the  right  superior  maxilla,  and  a  faint 
line  of  the  cicatrix  resulting  from  the  incised  wound  in  the  cheek.     Fig. 

99  shows  the  patient  as  he  appeared  one  year  before  the  accident ;  Fig. 

100  shows  the  final  result  of  the  treatment. 

Case  No.  II.  Henry  S.,  German,  age  35;  occupation,  laborer; 
employed  at  Armour's  packing  house,  ^^'as  admitted  to  the  hospital 
October  7,  1887,  one  hour  after  the  accident,  which  was  caused  by 
being  struck  across  the  bridge  of  the  nose  by  a  descending  elevator, 
while  he  was  in  the  act  of  looking  up  the  shaft.  When  admitted  he 
was  suffering  from  concussion  of  the  brain.  Examination  disclosed  a 
lacerated  wound  over  the  left  eye,  extending  across  the  nose  to  the 
right  eye.  The  finger  could  be  introduced  and  readily  passed  down 
into  each  orbit,  and  against  the  fractured  edges  of  the  nasal  and 
sphenoid  bones.  By  taking  hold  of  the  upper  teeth,  all  the  bones  of 
the  upper  face  were  found  to  be  movable;  when  the  mouth  was  open 
the  upper  teeth  rested  upon  the  loAver,  and  there  was  a  peculiar  and 
disagreeable  elongation  of  the  face.  A  later  examination  revealed  the 
fact  that  the  frontal  sinus  was  crushed  in,  the  nasal  and  lachrymal 
bones  comminuted,  all  the  bones  of  the  face  torn  loose  from  the  skull 
on  a  line  passing  through  the  orbits;  and  that  the  superior  maxillae 
were  separated  from  the  other  bones  of  the  face.  The  inferior  maxilla 
was  not  injured.  Several  loose  pieces  of  bone  were  removed  from  the 
region  of  the  inner  canthus  of  each  eye  by  the  house  surgeon.  The 
wound  was  treated  antiseptically,  stitched,  drainage-tubes  inserted,  the 
lower  jaw  bandaged  tightly  against  the  upper  teeth,  and  iced  cloths 
ordered  over  the  face  and  head.  Pulse  60;  temperature  97.4°.  Stimu- 
lants administered  freely.  Profuse  hemorrhage  occurred  during  the 
night,  and  vomiting  of  blood  every  few  hours  until  two  o'clock  on  the 
following  day.  Patient  became  conscious  during  the  night,  but  the 
other  symptoms  seemed  to  give  little  hope  of  a  final  recovery. 

The  temperature  reached  102.2°  on  the  8th,  at  4  p.m.,  and  fell  to 
normal  on  the  9tli.  No  brain  symptoms  developed,  and  the  patient 
rapidly  improved  in  general  condition  from  this  time.  Swelling  and 
suppuration  were  so  excessive  for  several  days  as  to  render  the  adjust- 
ment of  a  splint  impossible.  The  treatment  consisted  of  stimulants 
and  thorough  irrigation  of  the  wounds.  The  old  method  of  bandaging 
was  resorted  to,  but  proved  a  failure,  for  the  reason  that  the  lower 
jaw  could  not  be  held  sufficiently  closed  to  support  the  fractured  bones 
in  their  proper  position  without  obstructing  breathing  by  the  mouth. 
This  was  necessary,  as  nasal  breathing  was  at  the  time  impossible. 

Oct.  24.  Inserted  an  interdental  splint,  constructed  after  the  plan 
of  the  one  used  in  the  preceding  case  and  supported  from  the  head 
by  the  same  means.  The  case  progressed  favorably  and  was  dis- 
charged December  3,  the  bones  having  all  united. 


234 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


Dec.  24.  Patient  returned  complaining  of  double  vision.  The 
lens  of  the  left  eye  looked  cloudy,  and  traumatic  cataract  was  feared. 

April  I,  1888.  Patient  seems  entirely  well.  The  double  vision 
complained  of  has  passed  away  and  the  lens  has  cleared  up. 

The  occlusion  of  the  jaws  is  equally  good  with  that  in  Case  No.  I,, 
but  the  deformity  of  the  face  is  greater.  This  was  the  result  of  the 
loss  of  portions  of  the  nasal  bones  and  of  the  external  wall  of  the 
frontal  sinus,  and  from  adhesion  and  contraction  of  the  cicatricial  tissue 
over  these  locations  (Fig.  loi). 

Fig.  ioi. 


Case  II.     Final  Result  of  the  Treatment. 

Case  No.  III.  Joseph  J.,  Pole,  age  17  years;  employed  in  the 
printing  office  of  the  Chicago  Evening  Journal.  Was  admitted  to  St. 
Luke's  Hospital  at  4  p.m.,  May  9,  1889,  in  an  unconscious  condition,, 
and  within  an  hour  after  the  occurrence  of  the  accident, — a  blow  across 
the  left  orbit  from  a  descending  passenger  elevator  while  he  was  in  the 
act  of  looking  up  the  shaft. 

The  external  tissues  about  the  left  eye  and  right  side  of  the  chin 
were  badly  lacerated  and  bruised;  the  superior  maxillae  were  fractured 
upon  a  line  with  the  orbits  and  at  the  articulation  of  the  sphenoid  bone, 
and  so  displaced  that  the  posterior  portions  of  the  superior  maxillae 
hung  down  and  prevented  the  closing  of  the  mouth,  causing  a  separa- 
tion of  the  anterior  teeth  by  the  space  of  one-half  an  inch.  Upward 
pressure  applied  to  the  region  of  the  superior  molar  teeth  carried  the 


FRAC"rrKi:s  of  tiii-:  sui'FKIor   M.\.\ir.r,.i:,  lyrc.  235 

bones  into  position,  but  upon  removal  of  the  force  they  immediately 
fell  back  again.  The  bones  of  the  face  were  not  conuuinuted  as  in 
the  before-mentioned  cases,  but  they  were  freely  movable  upon  slight 
pressure. 

Swelling  was  very  great  from  effusion,  and  there  was  also  a  con- 
siderable protrusion  of  the  left  eye,  with  effusion  of  blood  into  the 
anterior  chamber.  The  face  and  eye  were  immediately  dressed  with 
cold  applications,  and  ice  applied  to  the  head.  Hemorrhage  was 
slight.  Later  in  the  evening  consciousness  returned,  and  at  no  time 
afterward  did  any  l3rain  complication  arise.  Pulse  60;  temperature 
normal.     Morphia  sulf.,  gr.  |,  was  administered  to  allay  the  pain. 

An  attempt  was  made  also  in  this  case  to  reduce  the  diastasis  of 
the  bones,  and  maintain  them  in  position  by  bandaging  the  jaws 
together,  but  this  could  not  be  borne  on  account  of  the  injury  to  the 
nasal  passages,  causing  inability  to  breathe  except  through  the  mouth, 
while  the  swelling  was  so  great  as  to  make  it  impossible  at  that  time 
to  take  impressions  of  the  jaws. 

May  10.  The  temperature  rose  to  100°  F.  On  the  12th  it  fell 
to  normal,  and  did  not  again  go  above  that  point. 

The  general  treatment  consisted  of  lic]uid  diet,  thorough  irriga- 
tion of  the  external  wound  and  of  the  mouth  every  hour  with 
Thiersch's  antiseptic  solution.  The  treatment  of  the  eye  was  placed  in 
the  hands  of  the  attending  ophthalmologist. 

May  14.  The  patient  was  up  and  doing  well.  Impressions  were 
taken  of  both  jaws,  and  an  interdental  splint  constructed  upon  the 
same  principles  as  in  the  other  cases. 

May  16.  Splint  inserted  and  supported  from  the  head,  bringing 
the  bones  into  their  normal  position.  The  appliance  was  worn  with 
comfort,  and  at  the  end  of  seven  weeks  the  patient  was  discharged 
cured. 

The  occlusion  of  the  teeth  is  normal.  There  is  no  deformity  of 
the  face,  and  but  for  the  loss  of  sight  in  the  left  eye,  and  a  small  scar 
upon  the  right  of  the  chin,  no  evidence  would  be  left  to  tell  of  so 
serious  an  injury  (Fig.  102). 

Case  No.  IV.  Mr.  A.  C,  German,  aged  40,  machinist.  Employed 
at  Armour's  packing  house.  Was  admitted  to  St.  Luke's  Hospital 
September  23,  1891,  very  soon  after  the  accident  occurred,  in  a  semi- 
unconscious  condition,  with  laceration  and  contusion  of  the  left  side 
of  the  face,  comminuted  fracture  of  the  left  malar  and  zygomatic  pro- 
cess and  nasal  bones,  fracture  of  the  superior  maxillse  through  the 
orbits,  with  separation  of  the  bones  of  the  face  from  the  s.kull.  The 
upper  bones  of  the  face  were  slightly  movable  in  all  directions.  On 
opening"  the  mouth  the  bones  sagged  down,  and  upon  closing  the  teeth 
together  the   bones  were   again   driven   upward.     The    displacement, 


236 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


however,  was  not  so  marked  as  in  Case  Xo.  I  or  No.  II.  The  injuries 
were  caused  by  the  patient  being  struck  upon  the  left  side  of  the 
face  by  the  corner  of  a  descending  elevator  while  he  was  working  in 
the  bottom  of  the  shaft.  The  same  treatment  was  adopted  in  this  case 
as  in  the  preceding  one,  and  with  entire  satisfaction.  The  case  was 
discharged  at  the  end  of  ten  weeks,  with  perfect  occlusion  of  the  teeth 
and  no  deformity,  saving  a  little  flattening  of  the  face  in  the  region  of 
the  left  malar. 

Case  No.  V.     Mr.  P.  C,  Irish,  aged  42,  roofer.     Admitted  to  St. 
Luke's  Hospital  a  few  minutes  after  the  accident,  on  October  7,  1893; 

Fig.  102. 


Case  in.    Final  Result  of  the  Treatment. 


the  patient  having  fallen  from  the  roof  of  the  new  Twelfth  street  Illi- 
nois Central  Depot,  Chicago,  a  distance  of  at  least  sixty  feet,  striking 
upon  the  scaffolding  in  the  descent,  and  sustaining  a  fracture  of  the  left 
humerus,  contusion  of  the  left  side  of  the  face,  a  simple  fracture  of 
the  lower  jaw  between  the  second  bicuspid  and  first  molar,  and  frac- 
ture of  the  superior  maxillae,  apparently  through  the  lines  of  the 
sutures.  Crepitation  and  mobility  were  distinctly  discernible,  but  dis- 
placement was  ver}^  slight. 

The  fracture  of  the  lower  jaw  was  treated  by  wiring  the  teeth 
together  upon  either  side  of  the  fracture,  and  the  application  of  the 
four-tailed  bandage.     The  support  of  the  lower  jaw  was  sufficient  to 


FRACTURES    OF   THE    SUPERIOR    MAXILL.F:,    ETC. 


237 


maintain  the  proper  position  of  the  fractures  of  the  superior  maxillae; 
consequently  a  splint  for  this  purpose  was  not  necessary. 

The  case  did  well  from  the  commencement.  The  patient  w^as 
discharged  at  the  end  of  seven  weeks,  cured,  and  with  no  deformity 
of  any  kind. 

Fig.  103  shows  a  recent  case  of  fracture  and  diastasis  of  the 
superior  bones  of  the  face  from  the  skull,  treated  by  the  interdental 
splint,  in  a  gentleman  past  seventy  years  of  age.     Union  of  the  bones 

Fig.  103 


i 

.    1 

i 

Fracture  and  Diastasis  of  the  Superior  Bones  of  the  Face. 


was  complete  at  the  end  of  four  weeks.  There  was  no  deformity  left 
from  the  injury  (which  was  caused  by  falling  from  a  ladder),  and  the 
occlusion  of  the  teeth  w-as  perfect. 

Fig.  104  is  a  Roentgen-ray  picture  of  a  case  of  horizontal  fracture 
of  the  superior  maxillje  in  a  soldier  who  was  thrown  from  his  horse, 
and  had  his  face  trodden  upon  by  another  horse  coming  up  from  the 
rear.  The  picture  shows  slight  displacement  of  the  bone  .backward. 
(From  the  collection  of  the  U.  S.  Army  General  Hospital,  Presidio  of 
San  Francisco.) 

In  constructing  the  interdental  splint  for  this  class  of  cases,  metal 


238  SURGERV    OF    THE    FACE,    MOUTH,    AND    JA\\'S. 

has  the  advantage  over  vulcanite,  in  that  it  is  not  so  clumsy,  does 
not  take  up  so  much  room  in  the  mouth,  and  is  less  liable  to  break. 

When  metal  is  used  the  upper  and  lower  sections  are  to  be  swaged 
separately,  and  afterward  soldered  together,  and  the  arms  attached 

Fig.    104. 


Horizontal  Fracture  of  the  Superior  Maxilla. 

in  the  same  manner.  A  better  adaptation  may  be  secured  by  making 
the  sections  by  the  electro-deposit  method,  then  soldering  them  to- 
gether and  attaching  the  arms  in  the  same  way.  If  a  more  elegant- 
looking  appliance  is  desired,  it  may  then  be  electro-plated  with  gold. 


CHAPTER    XXIV. 
DELAYED  UNION  AND  UNUNITED  FRACTURES. 

Union  of  Iracttired  bones  is  sometimes  delayed  beyond  the 
lime  usually  occupied  by  the  system  in  this  process  of  repair,  and  occa- 
sionally there  is  complete  failure  in  the  process,  resulting  in  what  is 
known  as  "luiitnitcd  fracture  or  false  joint."  Delayed  union  is  by  no 
means  an  uncommon  condition,  but  complete  failure  of  union  is  quite 
rare.  These  conditions  occur  most  often  in  the  long  bones  of  the  ex- 
tremities and  in  the  lower  jaw,  the  causes  which  operate  to  bring  about 
such  conditions  being  equally  applicable  to  fractures  in  both  locations. 
Delayed  union  and  ununited  fractures  are  the  result,  in  a  large  major- 
ity of  cases,  of  arrestation  of  the  process  of  callus  formation  before  it 
has  reached  the  stage  of  calcification  or  ossification.  In  others  it  is 
the  result  of  the  loss  of  osseous  tissue,  or  such  a  displacement  of  the 
fragments  as  to  leave  a  gap  too  large  to  be  bridged  by  a  continuous 
callus.  The  conditions,  however,  which  combine  to  cause  delayed 
union  and  ununited  fractures  do  not  seem  to  be  very  well  understood. 
In  some  cases  it  appears  to  be  an  inabilit}^  on  the  part  of  the  bone- 
producing  structures  to  form  new  bone.  (Warren.)  The  material 
thrown  out  by  the  inflammatory  process  is  absorbed,  but  no  new  bone- 
forming -material  takes  its  place,  and,  as  a  consequence,  the  fractured 
ends  of  the  bone  fail  to  unite,  and  there  is,  as  a  result,  an  ununited 
fracture.  Examination  of  the  bone  at  this  time  reveals  the  fact  that 
absorption  has  been  going  on  at  the  fractured  ends,  as  evidenced  by 
the  loss  of  the  sharp  edges,  and  their  more  or  less  pointed  form.  The 
ends  of  the  bone  in  these  cases  are  usually  bound  together  with  a  liga- 
mentous band  (Fig.  105  j.  In  some  cases  nature  attempts  to  develop  a 
false  joint  by  forming  a  capsule  which  invests  the  fractured  ends  of  the 
bone,  and  contains  a  clear  serum.  The  ends  of  the  bone  may  also  be 
covered  with  cartilage,  more  or  less  perfectly  representing  the  hyaline 
cartilage.  Occasionally  complete  absorption  of  the  bone  takes  place, 
but  this  result  is  exceedingly  rare.  Such  a  case  is  to  be  found  in  the 
Warren  Museum,  Boston,  in  the  arm  of  a  man  (Warren)  whose 
humerus  was  entirely  absorbed  after  fracture. 

As  a  rule,  fractures  of  the  lower  jaw  unite  with  surprisingly  good 
results,  notwithstanding  the  dif^culty  frequently  experienced  in  main- 

239 


240  SURGERY    OF    THE    FACE,    MOUTH,    AND   JAWS. 

taining  the  ends  of  the  fractured  bone  in  proper  apposition.  The 
rapidity  with  which  the  process  is  accompHshed  in  some  cases  is  also 
a  great  surprise.  Hamilton  refers  to  a  case  occurring  in  an  adult,  in 
which  consolidation  was  completed  in  seventeen  days;  he  also  states 
that  he  had  never  observed  a  case  in  which  union  did  not  eventually 
take  place,  although  the  process  had  been  delayed  until  the  eleventh 
week.  Cases  are  on  record,  however,  at  the  present  time,  in  consider- 
able number,  in  which  union  was  delayed  from  ten  to  twelve  weeks, 
and  of  ununited  fractures  with  false  joint,  which  had  been  successfully 
treated  after  a  lapse  of  eighteen  months,  as  in  one  case  reported  by 
Dr.  Physick,  and  in  another  treated  by  Dupuytren,  four  years  after  the 
receipt  of  the  injury,  which  was  caused  by  a  gunshot  wound. 

The  majority  of  the  cases  of  delayed  union  and  ununited  frac- 
tures occur  during  middle  life.  Old  age  is  not  so  potent  a  predis- 
posing cause  of  these  conditions  as  is  generally  supposed. 

Fig.  105. 


Fracture  of  the  Lower  Jaw  with  Irregular  and  Fibrous  Union.     (After  Malgaigne.) 

The  frequency  of  delayed  union  and  ununited  fractures  may  be 
estimated  from  a  study  of  Sommers  upon  fractures  seen  at  the  Zurich 
Clinic  during  seven  years.  There  were  489  cases  of  recent  fractures 
admitted  to  the  Clinic  during  this  time.  Out  of  this  number  there 
were  developed  sixteen  cases  of  delayed  union,  and  six  cases  of  un- 
united fracture. 

Causes. — The  causes  which  operate  to  produce  delayed  union  and 
ununited  fractures  are  twofold:  Predisposing  and  Exciting.  The 
former  are  Constitutional,  the  latter  Local. 

The  Predisposing  or  Constitutional  Causes  are  morbid  conditions  of 
the  general  system,  which  impair  nutrition  or  are  manifested  in  some 
peculiar  dyscrasia  or  cachexia.  Among  these  conditions  may  be  men- 
tioned extreme  old  age,  long  illness  from  continued  fevers  immedi- 
ately following  the  injury,  a  debilitated  condition  of  the  system  result- 
ing from  improper  or  insufficient  food,  profuse  hemorrhage,  pregnancy 
and  prolonged  lactation,  the  withdrawal  of  an  accustomed  stimulant, 
scorbutic,  tuberculous,  or  the  syphilitic  diatheses,  cancer,  rachitis,  and 
diabetes. 


DELAYED    UNION    AND    UNUNITED    FRACTURES.  24I 

In  fractures  occurring  during  gestation,  union  is  often  delayed 
for  a  considerable  period,  sometimes  until  after  delivery.  Padieu  de- 
scribes a  case  of  fractures  of  the  tibia  and  fibula  occurring  nine  days 
after  the  suppression  of  the  menses,  and  in  which  union  was  delayed 
until  the  end  of  gestation.  The  process  of  union  began  ten  days  after 
delivery,  and  was  completed  at  the  end  of  a  month. 

The  Exciting  or  Local  Causes  of  delayed  union  or  non-union  of 
fractures  of  the  lower  jaw  are  the  interposition  of  foreign  substances 
between  the  fractured  ends  of  the  bone,  such  as  loose  fragments  of 
bone,  a  luxated  tooth,  portions  of  muscle,  ligaments,  or  other  soft 
tissue  of  the  immediate  neighborhood,  a  large  blood-clot,  or  arrest  of 
circulation  by  tight  bandages,  long-continued  applications  of  cold  and 
moist  dressings,  suppuration,  caries  or  necrosis,  incomplete  reduction, 
and  mobility  at  the  point  of  the  fracture.  Gunshot  injuries  are  more 
prone  to  cause  non-union  than  any  other  form  of  fracture,  doubtless  on 
account  of  the  loss  of  bone-tissue  at  the  time  of  the  injury,  and  their 
greater  liability  to  cause  necrosis.  Neglect  and  improper  treatment 
are  also  frequent  and  important  causes  of  non-union. 

Fractures  occurring  within  the  synovial  or  articular  surfaces  are 
often  very  slow  to  unite,  and  occasionally  they  fail  altogether,  owing 
to  the  fact  that  the  soft  tissues  can  aid  very  little  in  the  accomplish- 
ment of  the  reparative  processes,  and  also  that  the  fractured  surfaces 
are  constantly  bathed  by  the  synovial  fluid. 

Hamilton  is  of  the  opinion  that  too  much  stress  is  laid  on  motion 
as  a  cause  of  delayed  union,  and  instances  fractures  of  the  ribs  and 
of  the  clavicle,  which  are  never  at  complete  rest,  to  support  his  opinion. 
Motion,  however,  in  these  locations  is  very  slight,  and  not  to  be  com- 
pared with  the  extent  of  motion  that  may  occur  in  an  extremity  or  in 
the  lower  jaw.  If  motion  is  sufflcient  to  cause  a  sliding  of  the  fractured 
ends  of  the  bone  over  each  other  in  any  direction,  union  is  delayed 
or  repair  may  be  prevented  altogether. 

The  formation  of  the  callus  takes  place  at  many  points  upon  the 
circumference  of  the  bone,  as  well  as  between  the  fractured  ends,  the 
process  appearing  when  completed  somewhat  like  that  employed  by 
the  plumber  in  uniting  two  ends  of  a  lead  pipe.  Plate  III  is  a  Roentgen- 
ray  picture  of  a  fractured  ulna  in  which  the  callus  is  forming  around 
the  ends  of  the  fractured  bone.  (From  the  collection  of  the  U.  S.  Army 
General  Hospital,  Presidio  of  San  Francisco.)  This  may  account  for 
the  fact  that  slight  motion  does  not  materially  interfere  with  the  process 
of  union. 

If,  however,  motion  is  considerable,  the  development  of  the  callus 
may  be  arrested,  the  fractured  ends  of  the  bone  become  rounded  from 
absorption,  and  a  so-called  false  joint  be  formed. 

In  those  cases  where  there  is  complete  failure  in  the  process  of 


242  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

repair,  necrosis  and  suppuration  sooner  or  later  supervene,  and  union 
will  not  take  place  until  after  the  dead  bone  has  been  exfoliated  and 
suppuration  has  ceased.  If  there  has  been  an  extensive  loss  of  bone- 
tissue  by  this  process,  union  cannot  take  place  through  the  ordinary 
process  of  repair,  but  nature  may  eventually  provide,  in  some  cases, 
an  adventitious  tissue,  in  the  form  of  fibrous  bands  or  fibro-cartilage, 
which  bind  the  fractured  ends  together.  Such  union,  however,  is  not 
very  strong,  yet  it  serves  in  a  measure  the  purpose  of  bone.  This  kind 
of  union  is  sometimes  formed  after  the  operation  of  resection  in  the 
long  bones,  and  in  the  lower  jaw  after  the  removal  of  necrosed  bone 
and  tumors  involving  the  body  of  the  jaw. 

Treatment  of  Delayed  Tlnion. — Examples  of  delayed  union  are 
quite  frequent,  and  are  often  met  with  in  fractures  of  the  lower  jaw, 
consolidation  of  the  callus  having  been  delayed  for  various  reasons. 
This  condition  in  hospital  practice  is  often  associated  with  the  drink 
habit.  Fractures  as  a  rule  do  not  unite  so  speedily  in  the  confirmed 
drunkard  as  in  other  individuals.  In  those  cases  dependent  upon  im- 
paired health  and  long  confinement  in  bed,  consolidation  will  eventu- 
ally, by  a  gradual  process,  take  place  as  the  health  and  the  surround- 
ings improve.  When  it  is  the  result  of  imperfect  reduction  or  mobility 
at  the  seat  of  the  mjury,  a  proper  reduction  of  the  fracture  and  the  ap- 
plication of  suitable  supports  for  maintaining  a  correct  apposition  of 
the  fractured  ends  of  the  bone  in  rigid  immobility  will  finally  result  in 
union. 

Treatment  of  TJnunited  Fractures. — The  only  real  difference  be- 
tween delayed  union  and  an  ununited  fracture,  is  one  of  time.  When 
union  is  not  complete  within  the  usual  period,  thirty  to  sixty  days  after 
the  injury,  the  case  is  termed  one  of  delayed  union,  even  though  consoli- 
dation has  not  taken  place  after  the  lapse  of  several  months,  but  gives 
hope  of  final  union  without  a  surgical  operation.  If,  however,  the  case 
gives  no  hope  of  union  without  surgical  interference,  after  the  lapse  of 
several  months,  it  is  termed  an  ununited  fracture. 

Various  methods  have  been  suggested  from  time  to  time  for 
stimulating  the  delayed  process  of  repair.  W'ilson,  in  1787,  suggested 
a  seton  passed  through  the  tissues.  Physick,  in  1802,  used  a  silk  rib- 
bon passed  through  the  ends  of  the  fractured  bone.  Somme  used  a 
silver  wire  loop.  Diefifenbach  perforated  the  ends  of  the  bone  with  a 
drill,  and  fastened  the  overlapping  fragments  together  with  ivory 
pegs.  Gaillard  suggested  the  perforation  of  both  ends  of  the  fracture 
with  a  metallic  trocar  and  canula.  Malgaigne  perforated  the  tissues 
with  the  acupuncture  needle.  Miller  penetrated  the  tissues  subcutan- 
eously  with  a  tenotome  knife.  Detmold  used  a  gimlet  for  the  same 
purpose,  and  Brainard  a  spear-pointed  drill.  M.  Mayor  used  tJTe 
actual  cautery,  and  others  have  used  caustics. 


DELAYED    UNION    AND    UNUNITED    FRACTURES. 


243 


< 

a. 


DELAYED    UNION    AND    UNUNITED    FRACTURES.  245 

The  most  satisfactory  method  for  the  treatment  of  this  condition 
in  the  lower  jaw  is  that  of  Professor  .Brainard,  w'hich  consists  in  mak- 
ing several  perforations  in  both  ends  of  the  bone,  causing  the  drill  to 
pass  freely  through  at  points  near  the  fracture,  and  then  firmly  fixing 
the  fractured  bones  by  means  of  the  interdental  splint  or  external 
splint,  or  by  wiring  the  bone  in  the  manner  described  in  a  preceding 
chapter. 

In  case  the  first  treatment  should  fail,  after  a  period  of  several 
weeks,  it  should  be  repeated.  The  writer  has,  however,  never  found  it 
necessary  in  operations  upon  the  lower  jaw  to  repeat  the  treatment, 
and  prefers  the  operation  of  suturing  the  jaw  with  wire  to  the  use  of 
the  interdental  splint,  as  the  presence  of  the  wire  seems  to  act  as  an 
added  stimulus  to  the  tardy  process  of  repair. 

Another  method  of  treatment  of  ununited  fractures  is  by  the  im- 
plantation of  bone  from  man  and  the  lower  animals.  Several  suc- 
cessful cases  are  to  be  found  reported  in  the  periodical  surgical  litera- 
ture of  the  past  fifteen  years.  Poncet,  in  January,  1887,  grafted 
a  portion  of  the  first  phalanx  of  the  great  foe,  measuring  about  one 
inch  in  length  and  half  an  inch  in  width,  taken  from  a  recently 
amputated  limb  of  a  healthy  man  forty-five  years  of  age,  into  the  mid- 
dle of  the  shaft  of  the  tibia  of  a  patient  nineteen  years  of  age,  who  had 
sustained  a  compound  fracture  thirteen  months  before,  which  from 
necrosis  had  failed  to  unite.  The  graft  did  well,  and  united  finely  with 
the  lower  fragment,  but  failed  by  about  a  quarter  of  an  inch  with  the 
upper  fragment,  to  w^hich  it  was  attached  by  a  weak  fibrous  band. 

McGill  reported  a  compound  fracture  of  both  bones  of  the  forearm 
in  a  young  man  of  twenty  years.  The  ulna  united,  but  the  radius  failed, 
and  three  months  later  w^as  wired  unsuccessfully.  One  year  after  the 
original  injury  (1889)  McGill,  after  freshening  the  ends  of  the  bone, 
which  left  a  gap  of  three-quarters  of  an  inch,  grafted  into  the  space 
thirteen  pieces  of  bone  chiseled  from  the  femur  of  a  freshly  killed  rab- 
bit. Five  weeks  later  there  was  firm  union,  and  at  the  end  of  four 
months  the  limb  was  as  useful  as  its  fellow. 

A  similar  case  w^as  reported  by  W.  H.  Sherwood.  In  this  case 
both  bones  of  the  forearm  had  failed  to  unite,  but  union  was  secured 
by  grafting  nine  segments  of  the  femur  of  a  rabbit,  each  of  which  was 
one-quarter  of  an  inch  thick.  Four  of  the  pieces  were  afterward  re- 
moved through  one  of  the  w^ounds,  which  had  failed  to  close.  Six 
months  after  this  operation  union  was  completed  and  the  man  was 
able  to  use  the  arm  at  his  usual  occupation. 

The  writer  reported  to  the  Ninth  Internationaf  Medical  Congress 
a  partially  successful  case  of  bone-grafting  in  the  lower  jaw  of  a 
woman.  The  gap  to  be  filled  was  one  and  a  half  inches  in  length,  and 
had  been  caused  by  a  resection  for  the  removal  of  an  osteo-sarcoma  of 
the  risfht  side  about  eisfht  vears  before. 


246  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

The  Operation  was  performed  in  January,  1887,  by  grafting  twelve 
small  pieces  of  bone  taken  from  the  lower  epiphysis  of  the  femur  of  a 
young  rabbit.  Union  took  place  with  the  ramus,  but  not  with  the 
anterior  fragment  of  the  bone,  leaving  a  gap  of  half  an  inch  yet  to  be 
filled.  A  second  operation  was  undertaken  in  May  of  the  same  year  to 
fill  this  gap  by  transplanting  a  piece  of  bone,  also  from  a  young  rabbit, 
sufficiently  large  to  fill  the  space,  but  this  failed  from  necrosis  after  six- 
teen days,  and  further  attempts  were  abandoned.  Fig.  106  shows  the 
apparatus  used  to  maintain  the  ends  of  the  jaw-bone  in  their  proper 
relations.  The  screw  was  set  into  the  ramus,  and  the  crown,  to  which 
a  tube  was  soldered  of  proper  size  to  receive  the  smooth  end  of  the 
screw,  was  cemented  to  the  bicuspid  tooth.  Extension  was  maintained 
by  a  set-screw  fitted  in  the  tube.  The  whole  was  constructed  of  23- 
carat  gold. 

Fig.   106. 


Crown. 


Sleeve. 
Appliance  for  Retaining  the  Ramus  in  its  Normal  Position,  during  Treatment 

BY  Bone-Grafting. 

Another  method  of  treatment  is  that  of  interstitial  injections  of 
10  per  cent,  solutions  of  chlorid  of  zinc.  Twenty  minims  of  the 
solution  is  injected  between  and  around  the  ends  of  the  fragments. 
Menard  reports  a  case  of  the  successful  issue  of  this  treatment  in  an 
ununited  fracture  of  the  leg  of  five  months'  standing,  in  which  union 
took  place  in  one  month  after  the  commencement  of  the  treatment. 
Glacial  acetic  acid  has  also  been  used  for  the  same  purpose,  injected  in 
six-minim  doses  between  the  ends  of  the  fragments.  Massage  of  the 
fractured  bones  and  overlying  tissues  has  been  highly  recommended 
by  some  authorities  as  an  efficient  method  of  promoting  the  reparative 
process. 

Treatment  of  fractures  and  delayed  union  by  internal  medication 
with  the  extract  of  the  thyroid  gland  has  recently  been  advocated  by 
Lambert,  chief  of  the  Surgical  Clinic  of  Lille  {Echo  Medical  du  Nord, 
1900). 

It  has  been  demonstrated  by  Hanan  and  Steinline,  who  reported 
their  observations  to  a  congress  held  in  Frankfort  in  1895,  that  the  re- 
moval of  the  thyroid  gland  produced  tardiness  in  the  union  of  broken 
bones  in  animals  thus  deprived,  and  suggested  the  use  of  thyroid 
medication  for  promoting  the  formation  of  callus.  This  idea  was  put 
into  practice  by  Gauthier,  who  recorded  in  the  Lyon  Medical,  1897,  the 
successful  use  of  this  method  of  treatment.  Queue  and  Folet  have  also 
found  it  efficient,  although  Folet  reports  failure  in  one  instance. 


DF.LAVKI)    UNION    AND    UNUNITED    FRACTURES.  247 

Lanil)crt  reports  that  l)v  this  treatment  the  union  of  fractured 
bones  is  hastened  and  that  tlie  time  required  l)y  nature  for  the  comple- 
tion of  the  process  of  repair  may  be  materially  shortened.  The  case 
reported  is  that  of  a  man  whose  tibia  and  fibula  were  broken  in  a  car- 
coupling  accident.  On  the  day  after  the  injury  he  was  put  upon  the  use 
of  capsules  containing  three  grains  of  the  thyroid  gland,  three  each 
day.  At  the  end  of  seventeen  days  union  of  the  fractured  bones  was 
found  to  be  solid.  The  appliances  were  removed  and  the  man  allowed 
to  get  up. 

There  is  good  reason,  therefore,  to  hope  that  this  means  of  shorten- 
ing the  period  of  treatment  of  fractured  bones  and  of  promoting  union 
in  ununited  fractures  will  prove  to  be  of  as  great  value  as  it  gives 
promise  of  being. 


CHAPTER    XXV. 

DISLOCATION  OF  THE  INFERIOR  MAXILLA. 

Definition. — Dislocation  (Lat.  dislocatiis— to  put  out  of  place). 
Luxation  (Lat.  luxatus — to  put  out  of  joint). 

A  dislocation  or  luxation  is  a  displacement  of  a  part  from  its 
proper  situation. 

Two  or  more  bones  whose  articular  surfaces  have  lost,  wholly 
or  in  part,  their  natural  connection  would  be  said  to  be  dislocated  or 
luxated,  and  the  condition  would  be  termed  a  dislocation  or  a  luxa- 
tion. 

Dislocations  in  general  are  classed  as  simple,  compound,  and 
complicated;  partial  and  complete;  recent  and  ancient;  primitive 
and  consecutive;  spontaneous,  traumatic,  and  relapsing;  pathologic 
and  congenital;  unilateral  and  bilateral;  single  and  double. 

A  Simple  Dislocation  is  one  without  other  important  injury  of 
the  joint,  and  with  no  communicating  wound. 

A  Compound  Dislocation  is  one  having  an  external  wound  which 
communicates  with  the  joint. 

A  Complicated  Dislocation  is  one  having  any  serious  lesion  not 
comprehended  under  the  term  compound,  especially  fracture  of  the 
misplaced  bones  at  their  articular  surfaces. 

Partial  Dislocations  are  those  in  which  some  portions  of  the  dis- 
turbed articulating  surfaces  continue  to  remain  in  contact. 

Complete  Dislocations  are  those  in  which  the  articular  surfaces  of 
the  bone  override  each  other. 

The  terms  Recent  and  Ancient  explain  themselves. 

A  Primitive  Dislocation  is  one  in  which  the  dislocated  surfaces 
remain  in  the  position  in  which  they  were  thrown  at  the  time  of  the 
luxation. 

A  Consecutive  Dislocation  is  one  in  which  the  dislocated  surfaces 
have  assumed  a  new  position.  This  is  usually  the  result  in  luxations 
of  long  standing. 

Spontaneous  Dislocations  are  those  which  are  not  caused  by  ex- 
ternal violence. 

Traumatic  Dislocations  are  those  which  occur  as  the  direct  result 
of  external  violence. 
248 


DISLOCATION    OF   THE    INFERIOR    MAXILLA.  249 

A  Relapsing"  Dislocation  is  one  which  is  prone  to  recur  on  very 
slight  provocation,  on  account  of  the  relaxed  state  of  the  ligaments, 
or  on  account  of  active  movement  of  the  joint  having  been  permitted 
before  repair  of  the  articular  capsule  was  completed  after  a  previous 
luxation. 

A  Pathologic  Dislocation  is  one  produced  by  a  diseased  state 
of  the  structures  of  the  joint. 

Congenital  Dislocations  are  those  which  are  present  at  the  time 
of  birth. 

When  bones  like  the  inferior  maxilla,  the  hyoid  and  sternum,  hav- 
ing a  median  position  in  the  body,  are  dislocated  upon  one  side  only, 
it  is  termed  Unilateral;  when  both  sides  are  luxated,  it  is  called  Bi- 
lateral. 

When  two  bones  corresponding  to  each  other,  in  opposite  sides 
of  the  body,  are  luxated  at  the  same  point,  it  is  termed  a  Double  Dislo- 
cation ;  but  when  only  one  is  luxated,  it  is  called  a  Single  Dislocation. 

Dislocations  occur  most  frequently  in  middle  life,  less  often  in  old 
age,  and  still  more  rarely  in  childhood. 

The  action  of  the  muscles  alone  sometimes  causes  a  dislocation, 
and  in  all  dislocations  caused  by  external  violence  the  muscles  play  an 
important  part.  It  is  almost  impossible  to  produce  a  dislocation  upon 
•the  cadaver  when  the  muscles  can  no  longer  take  part  in  producing  the 
displacement. 

As  a  rule,  the  force  which  causes  the  dislocation  of  a  long  bone 
is  applied  at  the  opposite  extremity,  rarely  at  the  point  of  dislocation. 

Dislocations  of  the  Lower  Jaw. — This  accident  is  rarely  met  with 
in  the  extremes  of  age,  but  is  most  common  during  middle  life.  It 
occurs  more  frequently  in  women  than  in  men. 

The  forms  of  luxation  of  the  inferior  maxilla  are  four  in  num- 
ber— complete,  incomplete,  unilateral,  and  bilateral. 

A  Complete  Dislocation  of  the  lower  jaw  is  that  condition  in 
which  one  or  both  condyles  have  been  forced  entirely  out  of  the 
glenoid  cavity.     (Fig.  107.) 

An  Incomplete  Dislocation  is  one  in  which  the  condyle  of  one  or 
both  sides  rests  upon  the  interarticular  cartilage,  directly  over  the 
articular  eminence. 

A  Unilateral  Dislocation,  as  the  term  implies,  relates  to  a  dis- 
placement of  one  side  only. 

A  Bilateral  Dislocation  is  one  in  w^hich  a  displacement  involving 
both  sides  has  occurred. 

The  great  majority  of  dislocations  of  the  temporo-maxillary  joint 
are  bilateral.  Out  of  twenty-eight  cases  mentioned  by  Giraldes,  fifteen 
were  bilateral;  of  seventy-six  cases  reported  by  Malgaigne,  fifty-four 
were  bilateral,  and  thirty-one  of  these  were  in  women. 


250  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

On  account  of  the  anatomy  of  the  temporo-maxillary  joint,  luxa- 
tion cannot  occur  backward,  upward,  or  outward;  consequently  the 
direction  of  the  dislocation,  when  uncomplicated,  is  forward.  When 
complicated  with  fracture  of  the  rim  of  the  glenoid  fossa  a  backward  or 
outward  dislocation  may  take  place,  but  without  fracture  of  the  bone 
the  dislocation  must  always  be  forward. 

The  temporo-maxillary  joint  is  an  arthrodial  joint,  and  provided 
with  an  interarticular  fibro-cartilage,  oval  in  form,  and  thicker  at  the 
margins  than  at  the  center.  A  pouch  of  synovial  membrane  is  in- 
terposed between  the  fibro-cartilage  and  the  glenoid  cavity,  and  be- 
tween the  articular  surface  of  the  condyle  and  the  fibro-cartilage  is  a 
smaller  synovial  pouch.  Occasionally  the  pouches  are  united  through 
a  deficiency  in  the  center  of  the  fibro-cartilage.  The  fibro-cartilage 
acts  as  a  buffer  to  prevent  shocks  from  a  violent  closing  of  the  jaw. 


Complete  Dislocation  ok  the  Lower  Jaw,  showing  the  Anatomical  Relations. 
(After  Sir  Astley  Cooper.) 

and  to  guard  against  injury  to  the  brain  through  the  thin  bony  plate 
of  the  glenoid  cavity.  The  joint  is  furnished  with  two  lateral  liga- 
ments, a  short  external  ligament,  extending  from  the  tubercle  of  the 
zygoma  to  the  outer  and  posterior  borders  of  the  neck  of  the  condyle, 
and  a  long,  flat  internal  ligament,  which  extends  from  the  spinous  pro- 
cess of  the  sphenoid  bone  to  the  inner  border  of  the  dental  foramen  on 
the  inner  side  of  the  ramus  of  the  jaw. 

The  Capsular  Ligament  consists  of  a  few  fibers  which  arise  from 
the  margin  of  the  glenoid  cavity,  and  blend  below  with  the  lateral  liga- 
ments. 

The  form  of  this  articulation  admits  of  free  motion  of  the  jaw 
from  side  to  side,  forward  and  backward,  upward  and  downward, 
thus  enabling  the  teeth  to  thoroughly  triturate  the  food. 

The  muscles  which  elevate  the  lower  jaw  are  the  temporal,  mas- 
seter,  and  internal  pterygoid.    The  fibro-cartilage  maintains  its  proper 


DISLOCATION    OF    THE    INFERIOR    MAXILLA. 


251 


relation  to  the  condyle  in  all  of  the  ordinary  movements  of  the  jaw, 
but  if  depression  of  the  jaw  is  carried  beyond  a  certain  limit,  a  forward 
dislocation  may  result. 

The  articular  eminence  at  the  inner  side  of  the  zygoma  is  coated 
with  cartilag-e,  and  is  in  contact  with  the  fibro-cartilage  of  the  joint  in 
front.  Ordinarily  the  condyle  never  reaches  the  top  of  the  eminence, 
although  it  glides  forward  when  the  mouth  is  wide  open.  When  the 
depression  of  the  jaw  is  strained  in  this  position,  the  external  pterygoid 
muscle  forcibly  contracts  and  draws  the  condyle  forward  and  over  the 
eminence  into  the  zygomatic  fossa,  leaving  the  fibro-cartilage  behind, 
while  the  condyle  becomes  more  or  less  fixed  in  its  new  position  by 
the  contraction  of  the  elevator  muscles. 


Fig.  108. 


Dislocation  of  the  Lovvkr  j.aw,  showing  Position  of  the  Mouth  and  Jaw  and 
THE  Depression  in  Front  of  the  Ear.     (After  Fergusson.) 

Causes.— The  Predisposing  Causes  of  dislocation  of  the  lower  jaw 
are  relaxation  of  the  articular  ligaments,  and  pathologic  changes  in  the 
structures  of  the  joint,  from  rheumatoid  arthritis. 

The  Exciting  or  Immediate  Causes  are  muscular  contraction  and 
violence  applied,  either  within  the  mouth  or  externally  upon  the  chin; 
yawning,  vomiting,  shouting,  immoderate  laughter,  or  anything  which 
opens  the  mouth  widely,  may  induce  a  dislocation.  Epileptic  convul- 
sions have  also  been  known  to  cause  it. 

Among  the  forms  of  violence  which  may  cause  the  accident  are 
operations  within  the  mouth,  like  taking  impressions,  plugging  the 
lower  teeth,  the  use  of  gags,  and  the  extraction  of  teeth.  The  forms 
of  external  violence  which  might  produce  the  luxation  are  falls  and 


252  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

blows  Upon  the  chin,  having  a  downward  direction,  and  occurring 
when  the  mouth  was  widely  extended. 

Symptoms. — The  diagnosis  of  a  recent  luxation  is  an  exceedingly 
simple  matter. 

The  symptoms  are  most  marked  when  the  dislocation  is  bilateral. 
Under  this  condition  the  mouth  is  extended  to  its  widest  limit  and 
firmly  fixed  in  that  position,  while  speech  and  deglutition  are  very 
greatlv  impaired.  The  jaw  is  thrust  forward  so  that  the  lower  teeth 
project  beyond  the  upper,  and  on  account  of  the  impaired  ability  to 
swallow,  the  saliva  constantly  dribbles  from  the  mouth.  Immediately 
in  front  of  the  tragus  of  the  ear  is  a  marked  depression  over  the  now 
emptv  glenoid  fossa,  while  by  passing  the  finger  under  the  lower 
border  of  the  malar  bone  the  coronoid  process  can  be  distinctly  felt. 
There  is  also  a  considerable  prominence  above  the  zygoma,  the  result 
of  the  contraction  of  the  temporal  muscle,  and  of  the  presence  of  the 
condyle  in  its  new  position.  (Fig.  108.)  When  the  dislocation  is  uni- 
lateral the  chin  will  be  carried  to  the  right  or  left,  according  to  the  loca- 
tion of  the  displacement.  If  the  left  side  is  dislocated,  the  chin  is  car- 
ried to  the  right,  and  vice  versa.  The  depression  in  front  of  the  ear 
will  be  found  only  on  the  injured  side.  The  other  symptoms  are  gen- 
erally the  same,  though  not  always  so  well  marked;  occasionally  they 
may  be  so  imperfectly  defined  as  to  escape  notice  altogether. 

Treatment. — The  reduction  of  dislocations  of  the  jaw,  if  of  recent 
date,  is  a  matter  of  easy  accomplishment;  but  when  the  luxated  jaw 
has  remained  unreduced  for  any  considerable  time,  adhesions  take 
place,  and  it  then  becomes  a  much  more  difificult  task. 

In  reducing  dislocations  of  the  jaw,  the  force  is  to  be  applied  in 
such  a  way  as  to  depress  the  angle,  while  at  the  same  time  the  chin 
is  carried  toward  the  superior  maxillae.  The  effect  of  this  application 
of  mechanical  force  is  to  depress  the  condyle  to  a  level  with  the  articu- 
lar eminence,  when  the  contraction  of  the  internal  pterygoid  muscle 
carries  it  back  into  the  glenoid  fossa. 

The  method  usually  employed  for  reducing  dislocations  of  the  jaw 
is  for  the  patient  to  be  seated  in  a  low  chair,  the  surgeon  taking  his 
position  directly  in  front. 

The  thumbs  of  the  operator  having  been  wrapped  with  a  few 
turns  of  bandage,  or  other  suitable  protection,  are  placed  upon  the 
ends  of  the  posterior  inferior  molars  of  either  side,  as  near  the  ramus  as 
possible,  the  fingers  of  each  hand  grasping  the  jaw  upon  the  outside; 
forcible  downward  and  backward  pressure  is  then  made  upon  the 
molar  teeth,  while  at  the  same  time  the  chin  is  elevated  with  the  fin- 
gers. This  liberates  the  condyle  from  its  false  position,  and  allows  it 
to  slip  over  the  articular  eminence  and  into  the  glenoid  fossa. 

Roth  has  recently  suggested  a  new  method  of  reducing  disloca- 


DISLOCATION    OF   THE    INFERIOR    MAXILLA.  253 

tions  of  the  jaws,  as  follows:  The  patient  is  seated  in  an  ordinary  chair, 
the  surgeon  standing  in  front  of  him  in  the  usual  way.  He  then  flexes 
himself  at  the  hips,  and  causes  the  patient  to  lean  forward  and  place 
his  forehead  on  the  breast  of  the  operator.  The  neck  of  the  operator 
is  now  flexed  so  that  the  chin  comes  in  contact  with  the  head  of  the 
patient  at  the  upper  portion  of  the  occipital  bone,  thus  securing  a  firm 
hold  of  the  head  between  the  chin  and  the  breast.  The  protected 
thumbs  are  now  inserted  into  the  patient's  mouth,  and  placed  upon 
the  inferior  molar  teeth,  while  the  fingers  of  both  hands  grasp  the 
lower  border  of  the  jaw,  and  force  is  applied  in  the  usual  manner. 

In  exceptional  cases  it  may  be  necessary  to  reduce  one  side  at  a 
time,  but  care  must  be  exercised  to  prevent  a  redislocation  of  the  con- 
dyle of  one  side  while  the  other  is  being  reduced. 

In  unilateral  dislocations,  efiforts  at  reduction  should  be  applied 
only  to  the  injured  side. 

Another  method,  which  was  first  suggested  by  Ambrose  Pare, 
is  often  valuable  in  those  cases  in  which  the  methods  just  described 
have  failed ;  this  is  to  place  wedges  made  of  cork,  wood,  or  soft  rubber, 
between  the  molar  teeth,  and  then  gradually  but  forcibly  carry  the 
chin  upward  toward  the  superior  maxillae.  The  position  of  the  opera- 
tor in  this  method  is  behind  the  patient,  whose  head  rests  upon  the 
breast  of  the  surgeon  or  upon  the  back  of  the  chair,  while  the  hands 
of  the  operator  are  placed  under  the  chin.  This  position  gives  perfect 
control  of  the  patient's  head,  a  matter  of  considerable  moment  if  the 
reduction  proves  dif^cult. 

By  using  the  wedges  in  this  manner,  the  principle  of  the  lever  and 
fulcrum  is  introduced;  the  jaw  acts  as  a  lever,  and  the  wedges  as  the 
fulcra.  The  condyles  are  thus  forced  downward  until  they  pass  the 
eminentia  articularis,  when  they  readily  slip  into  the  glenoid  cavity. 

Nelaton's  method  was  to  stand  in  front  of  the  patient  and  place 
the  thumbs  upon  the  coronoid  processes,  either  within  or  without  the 
mouth,  and  grasp  the  mastoid  processes  with  the  fingers,  gradually 
forcing  the  jaw  into  position;  or  sitting  behind  the  patient,  place  the 
thumbs  upon  the  nape  of  the  neck,  and  with  the  fingers  over  the 
ascending  ramus  endeavor  to  draw  the  jaw  backward  into  position. 

Dislocations  of  long  standing  are  often  difificult  to  manage,  on  ac- 
count of  the  inflammatory  adhesions  or  pathologic  changes  which  may 
have  taken  place  in  the  structures  of  the  joint.  Heath  mentions  the 
case  of  a  woman  for  whom  Pollock  successfully  reduced  a  dislocation 
of  four  months'  standing,  by  inserting  wedges  between  the  molar  teeth 
and  elevating  the  chin  by  means  of  a  strap  tourniquet  passed  over  the 
head.  Several  other  cases  are  on  record  in  which  successful  reduction 
was  accomplished  after  periods  ranging  from  thirty-five  to  ninety-eight 
days  after  the  accident.     In  these  cases  the  reduction  is  greatly  facili- 


.254  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

tated  by  the  use  of  anesthetics,  as  muscular  contraction  is  thereby  over- 
come, and  the  inflammatory  adhesions  are  more  readily  broken  up. 

Occasionally  dislocations  of  the  jaw  may  be  reduced  spontane- 
ously, or  with  no  other  assistance  than  that  which  the  injured  indi- 
vidual has  been  able  to  apply. 

Recurrent  dislocation  of  the  jaw  is  a  condition  dependent  upon 
the  existence  of  a  ruptured  capsule,  great  relaxation  of  the  articular 
ligaments,  or  some  change  in  the  form  of  the  articular  eminence.  Dis- 
locations of  this  character  are  exceedingly  rare. 

After  reduction  of  a  dislocated  jaw,  it  is  necessary  to  limit  its 
movements  for  a  week  or  ten  days  in  order  to  guard  against  the  possi- 
bility of  the  condyle  again  slipping  out  of  place,  and  also  to  give  rest 
to  the  injured  parts.  This  may  be  accomplished  by  the  application 
of  a  four-tailed  bandage,  and  prohibiting  talking  or  the  mastication 
of  food.  The  diet  should,  of  course,  be  limited  for  several  days  to 
liquid  food. 

In  cases  of  recurrent  dislocations  of  the  jaw,  the  tendency  may  be 
overcome,  as  suggested  by  Goodwillie,  by  the  adjustment  of  an  appa- 
ratus composed  of  a  netted  silk  cap  covering  the  chin,  and  attached 
by  elastic  bands  to  a  close-fitting  skull-cap  of  the  same  material,  rein- 
forced with  leather.  This  permits  the  ordinary  movements  of  the  jaw, 
but  at  the  same  time  prevents  the  opening  of  the  mouth  to  such  an  ex- 
tent as  to  allow  the  condyles  to  slip  out  of  position. 

Subluxation  of  the  Jaw. — Subluxation  of  the  jaw  is  a  condition 
in  which  the  condyle  partially  slips  from  the  glenoid  fossa  in  a  forward 
direction,  and  in  front  of  the  interarticular  cartilage,  when  the  mouth 
is  being  opened,  and  on  closing  it  the  condyle  goes  back  again  to  its 
place,  with  a  clicking,  snapping  sound.  Sometimes  it  catches  for  a 
moment  when  the  mouth  is  widely  extended,  and  causes  anxiety  on  the 
part  of  the  patient  for  fear  that  the  jaw  is  dislocated. 

This  condition  is  usually  seen  in  young  women  of  delicate  health 
and  physique,  and  in  certain  cases  of  malocclusion  of  the  teeth,  in 
young  subjects,  especially  in  those  having  a  short  or  underhung  jaw. 

Causes. — It  is  due  in  some  cases  to  a  relaxed  condition  of  the  artic- 
ular ligaments;  in  others  to  strain  upon  the  muscles  incident  to  an 
effort  to  obtain  a  comfortable  occlusion  of  the  teeth  in  mastication ;  and 
in  still  others,  in  all  probability,  to  changes  in  the  joint  as  a  result  of 
rheumatoid  arthritis.  The  exciting  causes  are  yawning,  biting  hard 
substances,  and  fatigue  from  operations  upon  the  teeth  which  necessi- 
tate a  long-continued  open  position  of  the  jaws. 

Treatment. — Reduction  is  generally  accomplished  by  the  subject 
of  the  accident  making  a  lateral  movement  of  the  jaw,  or  by  upward 
pressure  upon  the  chin.  External  support  may  sometimes  become 
necessary  to  overcome  the  tendency  to  the  accident,  as  already  de- 
scribed fcr  recurrent  dislocations. 


CHAPTER    XXVI. 
ANKYLOSIS  OF  THE  JAWS. 

Definition. — Ankylosis  (Greek  ajKvkoi,  meaning  a  stiffening  of 
the  joints  or  of  the  eyehds). 

The  coalescence  of  two  bones,  so  as  to  prevent  motion  between 
them. 

Immobihty  of  a  joint,  from  any  cause,  is  termed  Ankylosis. 

The  temporo-maxillary  articulation,  being  a  synovial  joint,  is  sub- 
ject to  the  same  class  of  diseases  that  affect  joints  of  like  structure  in 
other  portions  of  the  body,  and  with  corresponding  results. 

Ankylosis  of  the  jaws  may  therefore  be  classed  as  Temporary 
and  Permanent,  Incomplete  or  False,  Complete  or  Bony,  Fibrous  and 
Osseous,  Unilateral  and  Bilateral. 

Ankylosis  in  any  of  its  forms  is  the  result  of  injury,  accidental  or 
surgical,  or  of  disease. 

Temporary  Ankylosis. — Temporary  closure  of  the  jaws  is  a  con- 
dition of  tonic  spasm  of  the  muscles  of  mastication,  especially  of  the 
masseter  and  internal  pterygoid,  resulting  from  prolonged  and  severe 
irritation  of  the  third  division  of  the  trifacial  nerve,  and  inflammatory 
conditions  of  the  premaxillary  soft  tissues.  This  condition  must  not 
be  confounded  with  trismus,  the  result  of  tetanic  spasm  of  the  muscles 
of  mastication. 

Causes. — The  most  common  causes  of  this  affection  are  the  diffi- 
culties which  often  attend  the  eruption  of  the  inferior  third  molars,  or 
wisdom-teeth.  It  often  occurs  that  these  teeth  are  misplaced  in  the 
jaw,  or,  by  reason  of  the  shortness  of  the  horizontal  ramus,  there  is  not 
room  between  the  second  molar  and  the  ascending  ramus  for  the  third 
molar  to  make  its  exit.  As  a  consequence  of  these  conditions,  the 
eruption  of  these  teeth  is  slow  and  difficult,  or  altogether  impossible. 
The  effort,  therefore,  of  the  tooth  to  gain  its  normal  position  in  the 
dental  arch  superinduces  irritation,  which  may  be  made  manifest  either 
in  spasm  of  the  muscles,  or  in  a  suppurative  inflammation  of  the  alve- 
olar and  gingival  tissues,  or  an  extensive  periostitis  of  the  jaw  and 
cellulitis  involving  the  whole  side  of  the  face. 

Among  the  other  conditions  which  may  cause  a  temporary 
closure  of  the  jaws  may  be  mentioned  alveolar  abscess,  associated  with 

255 


256  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

the  molar  teeth  (usually  the  third  molars),  inflammation  of  the  parotid 
glands,  suppurative  tonsillitis,  and  necrosis  of  the  jaw. 

Treatment. — In  those  cases  dependent  upon  the  difficult  eruption 
or  the  non-eruption  of  the  third  molars,  the  first  effort  at  curing  the 
affection  should  be  directed  to  the  removal  of  the  cause.  This  cannot 
be  accomplished,  in  many  instances,  without  great  suffering  to  the  pa- 
tient, except  by  the  administration  of  a  general  anesthetic,  on  account 
of  the  rigidity  of  the  muscles  and  the  hypersensitive  condition  of  the 
tissues  involved. 

It  is  often  recommended  that  the  jaws  should  be  separated  by  slow 
degrees,  by  the  use  of  wedges,  the  screw-gag,  etc.,  in  the  hands  of 
the  patient.  This  procedure,  in  the  experience  of  the  writer,  has  never 
been  other  than  a  complete  failure,  for  the  reasons  that  the  patient 
will  not  persist  in  the  effort  on  account  of  the  severe  pain  often  in- 
flicted; and  when  the  attempt  has  been  made  by  the  surgeon,  he  has 
been  obliged  to  desist  for  the  same  reason. 

Fig.  109. 


Method  of  Applying  the  Screw  for  Opening  the  Jaws.     (After  Grady.) 

After  the  patient  is  profoundly  anesthetized  (complete  anesthesia 
is  always  necessary)  the  jaws  should  be  gradually  separated  by  means 
of  a  screw-gag  (Fig.  109),  lever,  or  other  device,  and  the  offending 
tooth  extracted.  This  can  best  be  accomplished  in  those  cases  where 
the  tooth  is  partially  erupted  by  the  aid  of  the  Physick  forceps.  The 
writer  has  rarely  found  it  necessary  to  extract  the  second  molar,  so 
often  advised  in  many  of  the  text-books,  as  a  necessary  operation,  in 
some  cases,  to  permit  the  extraction  of  the  third  molar.  With  proper 
instruments  and  ordinary  skill,  there  is  no  difficulty  in  the  way  of 
extracting  the  third  molar  which  cannot  be  surmounted. 

In  those  cases  in  which  the  tooth  is  impacted  the  gum-tissue  can 
be  excised,  the  covering  bone  cut  away  with  chisel  or  surgical  bur,  and 
the  tooth  lifted  from  its  crypt  with  elevator  or  forceps. 

In  exceptional  cases,  where  the  third  molar  is  in  a  horizontal 
position  in  the  jaw,  and  has  already  impinged  upon  the  roots  of  the 


ANKYLOSIS    OF    Till'.    JAWS.  257 

second  molar,  causing  absorption  at  the  point  of  contact,  it  becomes 
necessary  for  this  reason  to  extract  the  second  molar.  The  third  molar 
should  not  be  permitted  to  remain,  however,  even  under  these  cir- 
cumstances, if  there  has  been  any  suppurative  inflammation  in  connec- 
tion with  it,  on  account  of  the  liability  to  frequent  recurrence  of  the 
inflammatory  symptoms. 

The  irritation  rapidly  subsides  upon  the  removal  of  its  cause, 
and  the  jaw  soon  regains  its  normal  function. 

In  those  cases  associated  with  periostitis  of  the  jaw  and  cellulitis 
it  will  be  necessary  to  evacuate  any  accumulations  of  pus  within  the 
mouth,  if  possible,  and  irrigate  the  mouth  and  abscess-cavities  with 
antiseptic  solutions. 

When  the  closure  of  the  jaws  is  the  result  of  an  alveolar  abscess, 
the  ofifending  tooth  can  better  be  sacrificed  than  that  chances  be  taken 
of  a  recurrence. 

Cases  dependent  upon  inflammation  of  the  parotid  glands  and 
suppurative  tonsillitis  are  usually  of  short  duration,  the  function  of  the 
jaw  being  completely  restored  upon  the  subsidence  of  the  inflam- 
matory symptoms. 

When  it  is  the  result  of  necrosis  of  the  jaw,  a  restoration  of  the 
normal  function  of  the  joint  is  sometimes  delayed  for  a  considerable 
time,  depending  upon  the  location  and  the  extent  of  the  necrosis  and 
the  inflammation  and  swelling  of  the  adjacent  tissues. 

Permanent  Ankylosis. — Permanent  closure  of  the  jaws  is  a  much 
more  serious  condition  than  that  just  described.  In  this  form  of  the 
affection  articulation  is  imperfect,  the  mastication  of  food  impossible, 
and  when  the  teeth  are  tightly  closed  together,  as  frequently  occurs, 
deglutition  is  more  or  less  difficult,  and  in  some  cases  the  saliva  con- 
stantly dribbles  from  the  mouth,  making  the  condition  of  these 
patients  really  deplorable  in  the  extreme. 

This  form  of  the  affection  may  be  divided  conveniently  into  two. 
classes,  viz :  Incomplete  or  False  Ankylosis,  and  Complete  or  Trtre 
Ankylosis.  A  fibrous  or  cicatricial  ankylosis  (Fig.  no)  would  be 
classed  as  incomplete  or  false,  while  a  bony  ankylosis  would  be  classed 
as  true. 

Causes. — An  incomplete  or  false  ankylosis  may  be  either  intra- 
artfcular  or  extra-articular,  and  is  due  to  the  formation  of  fibrous 
adhesions  within  the  joint,  between  the  opposing  surfaces,  or  by  the 
deposition  of  fibrous  exudates  within  the  tissues  surrounding  the  joint; 
cicatrization  and  contraction  of  the  articular  ligaments  of  muscles  and 
integument,  following  injuries  of  an  accidental  or  surgical  nature; 
syphilitic  ulceration  of  the  oral  mucous  membrane,  ulcerative  mer- 
curial stomatitis,  and  gangrsena  oris  in  children. 

The  formation  of  cicatricial  bands  is  the  usual  result  of  extensive 

18 


258 


SUKGKRY    OF   THE    FACE,    MOUTH,    AND    JAWS. 


■.ulceration  and  loss  of  tissue;  similar  lesions  are  followed  by  a  like  result 
in  the  oral  mucous  membrane  and  cheeks.  The  cheeks  and  mucous 
membrane  of  the  mouth  are  exceedingly  elastic  in  their  normal  condi- 
tion, permitting  a  very  considerable  expansion  without  injury  to  their 
structure ;  but  when  the  character  of  these  tissues  has  been  changed  or 
replaced  by  a  mass  of  cicatricial  tissue,  elasticity  is  lost,  and  if  the  cica- 
trix involves  the  entire  cheek  from  one  jaw  to  the  other,  even  if  but  one 
side  is  affected,  it  will  as  completely  and  effectually  bind  the  jaws 
together  as  would  a  bony  ankylosis  of  the  articular  surfaces. 

Professor  Gross  says  bone  is  frequently  formed  in  the  new  tissue, 
.and  occasionally  assumes  the  form  of  an  osseous  bridge,  extending 
from  one  jaw  to  the  other,  and  thus  serves  to  more  firmly  bind  them 
logether. 

Fig.  iio. 


Cicatricial  Ankylosis.    The  Lips  only  could  be  opened  ;  Lower  Jaw  edentulous. 

(After  Weiss.) 


Complete  or  true  ankylosis  is  usually  the  result  of  disease  or  in- 
juries affecting  the  joint,  the  most  common  being  acute  arthritis  fol- 
lowing the  exanthematous  fevers,  in  connection  with  suppurative  con- 
ditions of  the  middle  ear  and  traumatic  injuries,  like  blows  upon  the 
side  of  the  face,  dislocations,  or  fractures  into  the  joint.  In  elderly 
persons,  chronic  rheumatoid  arthritis  may  sometimes  produce  the  affec- 
tion. Figs.  Ill  and  112  are  photographs  of  a  case  of  bilateral  ankylosis 
of  the  jaw,  taken  from  a  specimen  in  the  Pathological  Section  of  the 
Army  Medical  Museum,  Washington,  D.  C.  They  show  most  beauti- 
fully the  union  of  the  condyle  with  the  glenoid  cavity  upon  both  the 
right  and  left  sides. 

Diagnosis. — The  diagnosis  between  a  fibrous  and  an  osseous  an- 
Icylosis  can  only  be  determined,  in  many  cases,  by  placing  the  patient 


ANKYLOSIS    OF   THE    JAWS. 

Fig.  III. 


259 


Bilateral  Ankylosis  of  the  Jaw.    Right  Side. 


Fig.  112. 


Bilateral  Ankylosis  of  the  Jaw.    Left  Side. 


260  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

under  an  anesthetic.  If  the  ankylosis  is  fibrous,  slight  motion  will  be 
discovered  under  the  relaxation  produced  by  the  anesthetic,  and  by  the 
aid  of  a  screw-gag,  wedges,  or  levers,  the  jaws  may  be  forcibly  sepa- 
rated and  the  adhesions  broken  up;  while  on  the  other  hand,  if  the 
ankylosis  is  bony,  the  jaws  will  be  found  firmly  set,  and  all  ei'iforts  to 
separate  them  will  be  unavailing.  In  this  latter  form  there  is  a  coales- 
cence of  the  opposing  articular  surfaces,  producing  absolute  immo- 
bility. 

In  permanent  closure  of  the  jaws  the  causative  lesion  is  usually 
found  upon  one  side  only,  though  occasionally  both  sides  are  affected. 
In  bilateral  ankylosis  the  original  cause  of  the  difficulty  can  generally 
be  traced  to  disease  or  injury  affecting  but  one  side,  the  opposite  side 
becoming  affected  later,  as  a  consequence  of  disuse. 

When  a  joint  in  any  part  of  the  body  is  kept  motionless  for  a 
considerable  period  of  time,  the  bones  which  constitute  the  joint  take 
on  a  passive  inflammation,  with  the  exudation  of  plastic  lymph,  which 
later  becomes  organized,  resulting  in  a  fibrous  or  an  osseous  anky- 
losis. The  temporo-maxillar}'  joint  has  the  same  tendencies,  and  when 
rendered  motionless  through  cicatricial  contraction  of  the  cheek  and 
mucous  membrane  will  sooner  or  later  become  completely  ankylosed, 
unless  relieved  by  a  surgical  operation. 

Treaiment. — The  treatment  of  false  ankylosis  caused  by  contrac- 
tion of  the  mucous  membrane  and  muscles  of  the  cheek  is  by  no  means 
an  easy  task.  The  method  generally  suggested,  of  cutting  through 
the  cicatrix  and  separating  it  from  the  bones,  is  frequently  worse  than 
useless,  as  it  quickly  reunites,  leaving  an  augmented  area  of  cicatricial 
tissue,  which,  upon  secondary  contraction,  increases  the  difficulty  in- 
stead of  relieving  it. 

Heath  mentions  a  successful  case  described  by  Holt,  in  which,  by 
the  application  of  silver  shields,  adapted  to  the  teeth  of  the  upper  and 
lower  jaws,  extending  into  the  incisions  made  by  the  separation  of  the 
cheek  from  the  alveolar  walls,  and  the  removal  of  the  cicatrix  in  the 
mucous  membrane,  reunion  was  prevented,  while  eventually  the  de- 
nuded inner  surface  of  the  cheek  was  covered  with  a  normal  mucous 
membrane,  which  permitted  the  mouth  to  be  opened  to  its  fullest  ex- 
tent fFig.  113). 

Occasionally  the  transplantation  of  tissues,  as  suggested  by  Dief- 
fenbach,  will  in  a  measure  restore  the  normal  elasticity  of  the  cheek 
and  permit  the  jaws  to  be  opened;  but  unfortunately  it  rarely  happens 
that  a  sufficient  amount  of  healthy  mucous  membrane  remains  in  the 
locality  of  the  cicatrix  that  could  be  utiHzed  for  the  purpose  of  covering 
the  area  occupied  by  the  cicatricial  tissue. 

A  flap  of  skin  taken  from  the  immediate  neighborhood  was  trans- 
planted upon  the  inner  side  of  the  cheek  by  Jaesche,  with  good  results. 


ANKYLOSIS    OF    THE    JAWS. 


261 


Grafting,  after  the  Thiersch  method,  would  be  still  more  trouble- 
some to  aca)mplish,  on  account  of  the  difficulties  of  maintaining  the 
grafts  in  position  until  adhesion  had  taken  place;  yet  this  method  would 
be  worthy  of  a  trial  in  this  location  if  a  suitable  case  presented. 

Dieffenbach  recommends  the  formation  of  a  false  joint  upon  the 
affected  side,  bv  dividing  the  jaw,  section  of  the  bone  to  be  made  be- 
hind the  seat  of  the  cicatrix  in  the  ascending  ramus;  but  this  proves 
of  no  real  value,  as  the  impediment  to  the  mobility  of  the  jaw  lies  for- 
ward of  this,  through  the  cicatrix. 

Fig.  113. 


CICATRICIAL    ANKYLOSIS.      THE    RESULT    OBTAINED    BV   DlVSIOX    OE    THE    ^ll-^^l^^l^;;;/^^''- 

VENTiNG  Reunion  by  protecting  Silver  Shields  fitted  to  the  Teeth,  and  Gradual 
Separation  by  the  Use  of  Wedges.    (Holt,  after  Heath.) 


Fig.  114. 


Angular  Bone-Cutting  Forceps. 


Rizzoli's  operation  for  forming  an  artificial  joint  is  made  in  front 
of  the  cicatrix,  within  the  mouth,  the  object  in  operating  within  the 
mouth  being  to  avoid  a  scar  upon  the  external  tissues  of  the  face.  The 
operation  consists  in  first  dividing  the  soft  tissues  covermg  the  jaw, 
and  then,  with  powerful  cutting  forceps  (Fig.  114),  dividing  the  bone. 
The  disadvantages  of  this  operation  are  the  risks  of  sphntering  the 
bone,  and  the  tendency  of  a  mere  fracture  of  the  jaw— for  this  is  noth- 
in-  more-in  healthv  individuals  to  reunite.  He  claimed,  however,  to 
prevent  this  by  placing  a  piece  of  gutta-percha  between  the  ends  of  the 
bone. 


262  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

Esmarch's  operation  for  forming  a  false  joint  is  also  made  in  front 
of  the  cicatrix,  and  consists  in  removing  an  inverted  V-shaped  section 
of  bone,  through  an  external  incision  made  at  the  lower  border  of  the 
jaw.  The  section  can  be  made  very  neatly  and  quickly  by  a  small  cir- 
cular saw,  revolved  by  the  surgical  engine.  In  bilateral  ankylosis, 
both  sides  of  the  jaw  are  to  be  treated  in  the  same  manner.  Esmarch's 
operation  has  given  the  most  satisfactory  results,  and  is  more  gener- 
ally practiced  than  any  other.  Daily  motion  of  the  jaw,  however,  is 
necessary  after  an  operation,  to  prevent  the  formation  of  rigid  ad- 
hesions. 

The  treatment  of  false  ankylosis  of  the  jaws,  dependent  upon 
fibrous  adhesions  between  the  opposing  articular  surfaces  and  in  the 
tissues  about  the  joint,  presents  considerable  difficulty.  The  object  of 
any  form  of  treatment  must  be  the  restoration  of  the  mobility  of  the 
joint,  or  to  form  an  artificial  joint,  which  will,  in  a  measure  at  least, 
restore  the  function  of  the  jaws. 

Mechanical  Treatment. — In  exceptional  cases,  in  which  the  ad- 
hesions are  of  recent  formation,  mobility  of  the  joint  may  be  secured 
by  forcible  extension  of  the  jaws,  under  an  anesthetic,  by  means  of 
a  screw-gag,  or  wedges,  introduced  between  the  teeth.  The  adhesions 
by  this  procedure  are  broken  up,  and  mobility  obtained,  but  on  ac- 

FiG.  115. 


Goodwillie's  Appliance  for  Treatment  of  Fibrous  Ankylosis  of  the  Temporo-Maxil- 
LARY  Articulation.     (After  Goodwillie.) 

count  of  the  tendency  of  the  adhesions  to  reform,  it  becomes  necessary 
to  repeat  the  extension  of  the  jaws  daily,  for  weeks  and  months,  and 
even  then  it  is  not  always  successful, 

Goodwillie's  apparatus  (Fig.  115)  is  the  most  reliable  for  the  daily 
extension  of  the  jaws  which  is  so  necessary  after  any  of  the  operations 
for  cicatricial  ankylosis,  and  following  the  mechanical  method  of  treat- 
ment. 

In  cases  of  long  standing  the  mechanical  treatment  is  rarely  of 
any  permanent  value,  even  when  carried  out  in  the  most  persistent 
manner,  and  with  the  heartiest  co-operation  of  the  patient.  Most  sur- 
geons have,  therefore,  abandoned  this  line  of  treatment  as  offering 
very  little  inducement  from  the  curative  standpoint. 


ANKYLOSIS    OF    TITK    JAWS.  263 

Surgical  Trcafnicnt. — Subcutaneous  division  of  the  fil)rous  bands 
by  a  tenotome  introduced  into  the  joint  through  the  mouth  has  been 
frequently  tried,  and  with  somewhat  better  results.  The  constant  ten- 
dency, however,  to  a  reunion  of  the  divided  bands  is  a  serious  draw- 
back to  the  permanent  success  of  this  operation. 

The  operation  which  promises  the  best  results,  in  both  fibrous 
and  osseous  ankylosis,  is  excision  of  the  head  of  the  condyle  and  a 
portion  of  the  neck  of  the  jaw,  thus  forming  an  artificial  joint.  Less 
formidable  operations  for  establishing  an  artificial  joint  would  be  that 
of  Dieffenbach,  which  has  already  been  mentioned  as  dividing  the  as- 
cending ramus,  or  that  of  Esmarch,  which  removes  a  wedge-shaped 
segment  from  the  body  of  the  jaw  near  the  angle. 

The  method  of  procedure  usually  followed  in  excision  of  the  con- 
dyle is  that  described  in  Stimson's  "Manual  of  Operative  Surgery," 
viz: 

"An  incision  is  begun  at  the  lower  margin  of  the  zygoma,  close 
in  front  of  the  temporal  artery,  where  it  adjoins  the  ear,  and  carried 
forward  along  the  zygoma  i^  inch,  the  tissues  being  divided,  layer  by 
layer,  imtil  the  bone  is  reached.  A  second  incision,  involving  only  the 
skin,  is  then  carried  from  the  center  of  the  first,  directly  downward  for 
about  an  inch.  The  soft  parts  are  carefully  separated  with  elevator  and 
knife  from  the  margin  of  the  zygoma  and  the  outer  surface  of  the 
joint,  and  drawn  downward  with  a  hook,  thus  preserving  the  parotid 
nerves  and  vessels  from  injury.  The  neck  of  the  condyle  is  then  freed 
by  working  around,  in  front  and  behind,  with  a  small  elevator,  keeping 
close  to  the  bone,  so  as  to  avoid  injury  to  the  internal  maxillary  artery, 
and  finally  divided  with  a  chisel.  If  there  is  bony  union  between  the 
condyle  and  the  temporal  bone  (glenoid  cavity),  the  chisel  must  be 
again  used  to  separate  them,  its  edge  being  kept  directed  somewhat 
downward,  so  as  not  to  break  through  into  the  cavity  of  the  cranium."' 
Antiseptic  precautions  should  be  rigidly  carried  out  through  the  opera- 
tion and  in  the  after-treatment.  Drainage  for  the  wound  should  be 
provided;  but  this  may  be  dispensed  with  after  forty-eight  hours  if 
there  are  no  signs  of  inflammation.  Movements  of  the  jaw  may  be 
commenced  on  the  second  or  third  day  after  the  operation,  to  prevent 
the  formation  of  adhesions. 


CHAPTER    XXVII. 
PERIOSTITIS  OF  THE    JAWS. 

Definition. — Periostitis  (from  the  Greek  -£f>i — around,  dtrrer^ — 
bone,  and  c-ti — termination  used  to  indicate  inflammation).  Inflamma- 
tion of  the  periosteum. 

The  periosteum  is  a  fibrous  membrane  which  invests  or  covers  the 
external  surfaces  of  bones,  except  at  the  articular  surfaces  and  at  the 
points  of  insertion  of  tendons  and  ligaments.  It  is  composed  of  two 
layers — an  outer  or  fibrous,  and  an  inner  or  osteogenetic.  The  perios- 
teum serves  to  give  attachment  to  the  surrounding  tissues,  and  as  a 
means  of  nourishment,  growth,  and  regeneration  of  bone. 

Periostitis  of  the  Jaws. — The  jaws,  like  bones  in  other  parts  of  the 
body,  are  subject  to  inflammatory  conditions  of  their  periosteal  cover- 
ing, which  may  be  made  manifest  in  either  an  Acute  or  a  Chronic 
form. 

Acute  periostitis  of  the  jaws  may  be  either  a  simple  local  in- 
flammation, which  may  become  suppurative,  forming  subperiosteal 
abscesses,  or  it  may  be  diffuse  and  infective,  depending  upon  the  cause 
of  the  disease,  the  severity  of  the  attack,  and  the  diathesis  of  the 
patient.  In  an  individual  of  good  habit,  the  disease  would  in  all  proba- 
bility not  progress  beyond  a  simple  local  inflammation,  with  suppura- 
tion; while  on  the  other  hand,  if  the  individual  were  possessed  of  a 
strumous  or  tubercular  diathesis,  or  w-as  anemic,  or  recovering  from  a 
protracted  illness,  etc.,  the  inflammation  would  be  more  likely  to  take 
on  a  diffuse  or  infective  character. 

The  disease  may  terminate  either  in  resolution,  suppuration,  or 
necrosis. 

Simple  local  periostitis  is  the  most  common  form  of  the  disease. 
It  occurs  more  frequently  in  the  inferior  than  in  the  superior  maxilla, 
runs  a  more  rapid  course  when  located  in  the  lower  jaw,  and  almost 
invariably  terminates  in  necrosis  of  the  bone  unless  the  inflammatory 
symptoms  are  promptly  arrested.  Occasionally  the  disease  will  attack 
opposite  sides  of  the  jaw  at  the  same  time,  and  gradually  extend  until 
the  entire  jaw  is  involved ;  when  beginning  upon  one  side  only,  it  may 
cross  the  median  line  and  involve  the  jaw  of  the  opposite  side  to  a 
greater  or  less  extent. 

Causes. — The  exciting  causes  of  acute  local  periostitis  are  the  diffi- 
264 


PERIOSTITIS    OF    THE    JAWS.  265 

cult  eruption  of  tlie  deciduous  or  permanent  teeth,  irritation  from  de- 
vitalized teeth,  traumatic  injuries,  the  effects  of  the  eruptive  fevers, 
typhoid  conditions,  prolonged  anemia  in  young  children,  syphilis,  scor- 
butus, and  long  exposure  to  cold;  chemical  poisons,  such  as  mercury, 
carried  to  salivation,  and  the  vapor  of  phosphorus.  In  children  of 
tubercular  diathesis  the  disease  may  occur  with  no  other  evidence  of 
the  cause  than  the  constitutional  taint,  as  is  frequently  observed  in 
periostitis  of  other  portions  of  the  body. 

The  predisposing  causes  are  the  scrofulous,  tubercular,  and  syphil- 
itic diatheses,  and  all  other  conditions  which  produce  a  lowered  vitality. 

Symptoms. — The  symptoms  of  the  disease  are  elevation  of  tempera- 
ture, with  general  constitutional  disturbance;  swelling  and  congestion 
of  the  gum  and  of  the  affected  side  of  the  face;  severe,  tense,  bursting 
pains,  generally  worse  at  night;  the  teeth  become  loose  and  raised 
from  their  alveoli;  pressure  or  percussion  upon  the  teeth  causes  ex- 
cruciating pain.  The  swelling  often  extends  down  the  neck,  and  when 
pus  forms  it  may  point  beneath  the  jaw,  or  burrow  downward  between 
the  muscles,  following  the  connective  tissue,  and  point  at  various  loca- 
tions above  or  even  below  the  clavicle.  Spasmodic  closure  of  the  jaws 
is  not  an  infrequent  accompaniment  of  the  disease. 

In  the  milder  cases  of  simple  acute  periostitis,  the  disease  may  be 
very  insidious  in  its  approach.  The  pain  is  intermittent,  usually  oc- 
curring at  night;  the  swelling  of  the  gum  and  side  of  the  face  is  less 
marked,  and  may  be  overlooked  altogether,  while  the  teeth  may  not 
give  evidence  of  being  sore,  unless  sharply  percussed.  For  these  rea- 
sons advice  may  not  be  sought  and  the  disease  not  recognized  until 
considerable  mischief  has  been  done  by  the  formation  of  periosteal 
abscesses  and  death  of  the  bone. 

The  general  tendency  of  acute  periostitis  is  to  end  in  suppuration. 
When  suppuration  occurs  the  periosteum  is  dissected  from  the  bone, 
and  necrosis  is  induced. 

Acute  Diffuse  Periostitis. — This  form  of  the  disease  occurs  most 
frequently  at  the  age  of  puberty,  in  children  of  strumous  habit,  and 
those  sufifering  from  impoverished  conditions  of  the  blood.  It  runs  a 
more  rapid  course  than  simple  acute  periostitis,  the  general  and  local 
symptoms  are  more  aggravated,  pus  accumulates  in  greater  quantity, 
and  the  disease  invariably  ends  in  necrosis  of  the  bone. 

Causes. — The  direct  or  exciting  causes  of  the  disease  are  external 
injuries,  septic  infection,  eruptive  fevers,  exposure  to  cold  and  damp- 
ness, etc.  Occasionally,  in  young  children  of  tubercular  or  strumous 
■diathesis,  a  considerable  portion  of  the  jaw  may  become  necrosed 
without  any  previous  history  of  injury,  exposure,  derangement  of 
health,  or  other  discoverable  cause  which  seems  adequate  to  account 
for  the  disease. 


266  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

Treatment. — The  treatment  of  acute  simple,  and  of  diffuse  perios- 
titis, if  recognized  in  their  eadier  stages,  should  consist  of  energetic 
measures:  the  extraction  of  devitalized  teeth,  local  depletion  by  free 
scarification  of  the  gum,  cold  applications,— or  if  these  prove  painful, 
hot  fomentations,  or  hot  water  held  in  the  mouth, — and  opiates  to  re- 
lieve the  pain. 

When  the  inflammatory  process  has  reached  the  suppurative  stage, 
the  sooner  the  evacuation  of  the  pus  is  secured  the  better.  Free  in- 
cisions down  to  the  bone,  made  from  within  the  mouth,  ought  to  be 
insisted  upon  as  soon  as  pus  is  discovered,  v;ith  the  view  of  giving  exit 
to  the  discharges  and  relieving  the  periosteal  tension.  Such  a  proced- 
ure affords  great  relief  to  the  patient. 

When  the  abscess  points  toward  the  external  surfaces  beneath 
the  jaw,  as  frequently  happens,  or  burrows  down  the  neck,  external  in- 
cisions become  necessary,  as  evacuation  and  drainage  are  thus  better 
accomplished.  Irrigation  with  antiseptic  solutions  should  be  fre- 
quently employed,  and  if  necrosis  results  the  dead  bone  should  not  be 
removed  until  separation  has  taken  place.  The  constitutional  treat- 
ment must  be  sustaining  throughout,  viz:  good  foods,  tonics, — iron, 
cod-liver  oil,  etc., — and  stimulants  if  indicated. 

Mercurial  Periostitis. — This  form  of  the  disease  is  due  to  the  con- 
stitutional impression  of  mercury,  and  has  been  so  common  in  the  past 
as  to  come  under  the  notice  of  almost  every  middle-aged  practitioner  of 
medicine. 

The  effects  which  are  produced  by  mercury  upon  the  general  sys- 
tem, and  locally  in  the  mouth,  depend  upon  the  quantity  administered 
and  the  susceptibility  of  the  individual  to  the  action  of  the  drug.  Chil- 
dren from  five  to  ten  years  of  age  are  peculiarly  susceptible.  There 
is,  however,  a  very  great  variety  in  the  susceptibility  of  different  in- 
dividuals; in  one,  an  ordinary  dose  of  blue  pill  or  of  calomel  will  pro- 
duce severe  salivation  and  swollen  tongue,  while  another  seems  to  be 
almost  proof  against  its  action,  even  in  large  and  repeated  doses. 

Garretson  mentions  a  case  under  his  care,  a  child  seven  years  of 
age,  in  whom  necrosis  of  the  left  half  of  the  body  of  the  lower  jaw  was 
produced  by  the  administration  of  three  grains  of  calomel. 

Symptoms. — The  symptoms  of  the  disease,  as  presented  in  stages, 
are  a  coppery  or  metallic  taste  in  the  mouth,  speedily  followed  by  an 
increase  in  the  flow  of  saliva  and  swelling  of  the  tongue.  The  tongue 
in  its  swollen  condition  presses  upon  the  teeth,  causing  indentations 
upon  its  edges.  The  gums  next  become  swollen  and  puffy,  commenc- 
ing generally  in  the  neighborhood  of  the  inferior  incisor  teeth.  A  con- 
gested condition  of  the  oral  mucous  membrane  also  appears,  extending- 
over  the  entire  mouth,  and  sometimes  associated  with  a  sense  of  dry- 
ness or  of  burning.     Tumefaction  of  the  gums  now  becomes  general; 


PERIOSTITIS    OF   THE    JAWS.  267 

they  assume  a  livid  color,  and  bleed  easily.  The  salivary  glands  are 
swollen  and  tender,  and  the  secretion  of  saliva  is  greatly  augmented  in 
amount;  so  much  so,  that  the  patient  is  obliged  to  constantly  expector- 
ate. In  some  cases  the  secretion  is  so  profuse  that  it  runs  from  the 
mouth.  The  quantity  in  severe  cases  may  reach  several  pints  per  day. 
The  teeth  frequently  become  loose,  and  can  be  picked  out  with  the 
fingers;  the  breath  and  secretions  have  a  very  disagreeable  fetid  odor. 
The  disease,  if  unchecked,  may  be  complicated  with  necrosis  of  more 
or  less  extensive  portions  of  the  alveolar  process,  or  of  the  entire  jaw, 
or  with  sloughing  of  the  gums  and  cheeks. 

Treatment. — The  treatment  of  mercurial  periostitis  consists  of 
eliminating  the  mercury  from  the  system  by  the  aid  of  the  iodid  of 
potassium  in  doses  of  from  five  to  ten  grains  in  solution,  after  meals, 
which  forms  soluble  compounds  with  the  mercury  retained  in  the 
economy;  or  by  the  administration  of  chlorate  of  potassium  in  ten-  to 
fifteen-grain  doses  every  few  hours,  for  its  oxidizing  effects  in  contam- 
inated conditions  of  the  blood.  Saline  cathartics  are  also  useful  in 
promoting  elimination.  The  general  health  should  be  built  up  by 
change  of  air,  generous  diet,  and  tonics.  The  local  conditions  are  to 
be  corrected  by  scarifying  the  gums  and  painting  them  with  the  tinc- 
tures of  aconite  and  iodin,  equal  parts,  or  tincture  of  iodin  and 
glycerin,  equal  parts.  Solutions  of  chlorate  of  potassium,  one 
drachm  to  an  ounce  of  water,  used  as  a  mouth-wash,  will  be 
found  very  efficacious  in  relieving  the  local  inflammatory  con- 
ditions, and  can  be  used  ad  libituni.  Permanganate  of  potassium,  two 
to  ten  grains  in  an  ounce  of  water,  or  cinnamon  water,  are  very  useful 
in  correcting  the  fetid  odor  of  the  breath.  Solutions  of  boric  acid  and 
the  Thiersch  solution  may  be  used  freely  as  antiseptic  washes. 

Chronic  Periostitis  of  the  Jaws. — This  form  of  the  disease  is 
usually  the  result  of  syphilis.  It  is  generally  painless,  causes  but  little 
swelling  of  the  soft  tissues,  and  manifests  itself  in  the  formation  of 
nodes,  as  in  syphilitic  periostitis  of  other  parts  of  the  body.  The  palate 
and  alveolar  borders  are  particularly  liable  to  those  enlargements,  which 
are  due  to  exudations  between  the  periosteum  and  the  bone,  and  unless 
constitutional  treatment  is  instituted  for  their  removal,  necrosis  will 
sooner  or  later  supervene.  Fortunately,  the  disease  will  usually  yield 
to  large  doses  of  the  iodid  of  potassium,  twenty  grains  three  times 
per  day,  in  the  compound  syrup  of  sarsaparilla,  rapidly  increased  to 
drachm  doses.  Sy  this  treatment  in  a  few  weeks  the  swelling  will  dis- 
appear, and  the  periosteum  be  restored  to  its  normal  condition.  Mer- 
cury is  generally  considered  to  be  inadmissible  in  this  form  or  stage  of 
syphilitic  disease. 


CHAPTER    XXVIII. 

NECROSIS  OF  THE  JAWS. 

Definition. — Necrosis  (from  the  Greek  •^^y.poi,  dead).  Death  of 
the  bone  en  masse. 

Necrosis  is  a  condition,  not  a  disease.  It  is  rather  a  symptom, 
representing  a  local  condition,  which  may  be  brought  about  by  various 
causes. 

Necrosis  of  the  Jaws. — Necrosis  is  much  more  common  in  the 
lower  than  in  the  upper  jaw.  This  is  no  doubt  due  mainly  to  the 
greater  vascularity  of  the  tissues  of  the  upper  jaw,  and  the  free  anas- 
tomosis of  its  vessels,  which  augments  its  recuperative  power;  and,  in 
comparison  with  the  lower  jaw,  its  better  protected  position,  which 
renders  it  less  liable  to  injury. 

The  superior  maxillae  are  supplied  with  numerous  branches  of 
the  internal  maxillary  arteries,  which  freely  inosculate  with  one  an- 
other and  with  those  from  the  opposite  side,  while  the  inferior  maxilla 
is  supplied  with  only  one  small  branch  upon  each  side,  and  these  do  not 
so  fully  anastomose  one  with  the  other. 

According  to  Stanley  ("Diseases  of  the  Bones"),  the  lower  jaw 
stands  fifth  among  the  bones  of  the  skeleton  in  its  liability  to  necrosis, 
while  the  upper  jaw  occupies  the  twelfth  place.  Taking  this  state- 
ment as  our  authority,  the  lower  jaw  is  therefore  nearly  two  and  a  half 
times  more  liable  to  necrosis  than  the  upper. 

Necrosis  of  the  jaws  may  be  complete  or  partial.  It  is  complete 
when  the  entire  thickness  of  the  bone  is  involved,  and  partial  when  it 
is  confined  to  the  alveolar  process. 

Causes. — The  causes  which  produce  necrosis  are  identical  with 
those  of  periostitis,  viz:  traumatisms,  the  eruptive  fevers,  scorbutus, 
syphilis,  inflammatory  conditions  of  the  periosteum  and  periodonteum, 
mercurial  and  phosphorus  poisoning,  local  arsenical  poisoning,  gan- 
grgena  oris,  and  other  ulcerative  affections  of  the  soft  tissues  of  the 
mouth,  which  establish  inflammatory  conditions,  causing  death  of  the 
bone  by  strangulation  of  its  blood-vessels.  Necrosis  in  this  respect 
resembles  gangrene  of  the  soft  tissues. 

Necrosis  is  therefore  the  result  of  unchecked  periostitis,  or  sup- 
purative inflammation,  induced  by  any  of  these  conditions,  and  the 
268 


NECROSIS    OF    THE   JAWS.  269 

separation  of  the  periosteum  from  the  bone  by  the  accumulation  of  the 
pus. 

In  the  upper  jaw,  which  is  composed  of  thin  plates  of  bone,  cov- 
ered upon  both  sides  with  periosteum,  and  the  whole  exceedingly  vas- 
cular; and  in  the  long  bones,  where  there  is  medullary  tissue  abun- 
dantly supplied  with  blood-vessels,  the  resistance  and  recuperative 
powers  are  much  greater  than  in  the  lower  jaw,  and  it  frequently  occurs 
that  after  an  extensive  subperiosteal  abscess  has  formed,  and  the  bone 
has  been  denuded  of  its  periosteum,  recovery  has  taken  place  without 
death  of  the  bone;  but  when  the  same  conditions  are  associated  with 
the  lower  jaw,  it  rarely  happens  that  recovery  takes  place  without  more 
or  less  extensive  necrosis,  while  death  of  the  bone  is  not  infrequently 
accomplished  in  a  few  hours  after  the  formation  of  pus  between  the 
periosteum  and  the  bone.  The  necrotic  process  does  not,  however, 
necessarily  extend  to  the  entire  thickness  of  the  bone,  but  may  be 
confined  to  the  outer  surface  only, — which  it  usually  attacks  first, — if 
proper  treatment  is  instituted  to  remove  the  accumulated  pus  and  con- 
trol the  inflammation.  In  such  cases  the  internal  plate  of  the  alveolar 
process  remains  intact,  and  gives  support  to  the  teeth,  which  other- 
wise would  loosen  and  fall  out,  as  generally  occurs  when  the  entire 
thickness  of  the  jaws  is  necrosed.  If,  however,  the  disease  involves  the 
entire  thickness  of  the  bone,  it  may  not  extend  beyond  the  alveolar 
process,  the  base  of  the  jaw  being  left  intact. 

Separation  finally  takes  place  between  the  living  and  the  necrosed 
portions  of  the  bone.  The  dead  portion  is  termed  the  sequestrum.  It 
frequentW  happens  in  the  lower  jaw,  but  rarely  in  the  upper,  that 
new  bone  is  formed  from  the  periosteum  over  and  around  the  seques- 
trum. This  shell  of  new  bone  is  termed  the  inxiolucrum.  The  new  shell 
of  bone  often  has  openings  in  it,  which  are  termed  cloacce. 

In  the  more  serious  cases  affecting  the  inferior  maxilla,  large 
sections  of  the  entire  thickness  of  the  jaw,  or  even  the  entire  jaw,  from 
the  articulation  of  one  side  to  that  of  the  other,  may  become  necrosed. 
Similar  conditions  may  prevail  in  the  upper  jaw,  but  it  is  exceedingly 
rare  that  the  necrosis  is  so  extensive  as  in  the  lower  jaw. 

Several  cases  of  an  interesting  character  have  come  under  the  ob- 
servation of  the  writer,  which  will  serve  to  illustrate  the  above  state- 
ments,— one  in  which  the  trouble  followed  tropical  fever  in  a  man 
thirty  years  of  age,  and  which  began  upon  the  right  side  of  the  jaw,  in 
the  region  of  the  first  molar  tooth.  Soon  afterward  it  attacked  the 
opposite  side,  and  extended  forward  to  the  median  line  on  both  sides, 
and  backward  to  the  angles.  The  necrosis  was  principally  confined 
to  the  external  plate  of  the  alveolar  process,  which  came  away  in  sec- 
tions and  spiculge  to  the  number  of  over  fifty,  and  involved  the  loss 
of  three  anterior  teeth.    Another  was  the  result  of  suppurative  inflam- 


270 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


mation  of  the  left  lower  third  molar  in  a  man  fifty  years  of  age,  suffer- 
ing from  anemia.  The  necrosis  extended  rapidly  until  the  entire 
alveolar  process  was  involved  from  the  left  angle  to  the  right  second 
molar.  All  of  the  teeth,  and  the  entire  alveolar  process,  were  lost  be- 
tween these  points.  A  third  was  the  result  of  scarlet  fever  in  a  l)oy  five 
vears  of  age,  in  whom  the  body  of  the  jaw,  from  the  right  lower  first 
deciduous  molar  backward,  and  the  entire  ramus,  including  the  con- 
dyle and  the  coronoid  process,  were  lost.  A  fourth  (Fig  116)  was  the 
result  of  a  suppurative  inflammation  of  the  left  inferior  third  molar  in  a 
woman  thirty-five  years  of  age,  suffering  from  general  debility,  the 

Fig.  116. 


Necrosis  of  Lower  Jaw  and  Sloughing  of  Soft  Tissues  of  Chin  and  Neck. 


result  of  frequent  gestations,  with  short  intervals,  and  overwork.  The 
necrosis  extended  very  rapidly  until  it  involved  the  entire  jaw,  which 
was  finally  lost  from  the  articulation  of  the  left  side  to  the  upper  third 
of  the  ascending  ramus  of  the  right  side.  This  case  terminated  fatally 
from  exhaustion  complicated  with  la  grippe,  sixteen  days  after  the  re- 
moval of  the  necrosed  maxillary  bone.  The  illustration  shows  exten- 
sive loss  of  the  soft  tissues  of  the  chin  and  neck  by  sloughing,  which 
had  occurred  before  the  patient  was  admitted  to  the  clinic  at  Mercy 
Hospital.  Another  was  in  a  boy  of  seven  years  of  age,  the  result  of  a 
severe  attack  of  measles,  in  which  the  alveolar  process  and  body  of  the 
right  superior  maxilla  from  the  canine  fossa  backward  to  the  tuber- 
ositv,  and  upward  to  the  orbital  plate,  was  lost,  the  palate  process  and 


NECROSIS    OF    THE    JAWS.  271 

the  orbital  plate  remaining-  intact.     Others  of  an  equally  grave  nature 
might  be  mentioned,  but  these  are  sufficient  to  illustrate  the  subject. 

Syinptoiiis. — The  earl}-  symptoms  of  necrosis  are  usually  those  of 
periostitis,  which  have  already  been  mentioned  under  that  head.  After 
necrosis  has  been  established  the  pus  finds  an  outlet  by  the  side  of 
the  loosened  teeth,  or  burrows  through  the  gums.  Later  the  gums 
become  loosened  from  the  bone,  and  the  pus  oozes  from  between 
them.  This  is  the  usual  course  of  necrosis  in  the  upper  jaw.  When 
associated  with  the  lower  jaw  it  often  burrows  through  the  tissues  cov- 
ering the  body  of  the  bone,  and  points  upon  the  under  side  of  the  jaw, 
or  follows  the  inter-muscular  connective  tissue  of  the  neck  downward, 
pointing  at  various  locations,  even  as  low  down  as  the  clavicle  or 
mamniK.  The  discharges  have  the  peculiar  fetid  odor  which  is  char- 
acteristic of  dead  bone,  and  in  those  cases  in  which  the  pus  is  dis- 
charged into  the  mouth  in  considerable  quantity,  nausea  and  vomiting 
may  ensue,  digestion  soon  becomes  deranged  by  reason  of  the  en- 
trance into  the  stomach  of  the  foul  discharges,  general  emaciation  fre- 
quently takes  place,  and  septicemia  is  not  an  uncommon  sequence. 

Necrosis  of  the  jaws  has  been  known  to  extend  to  adjacent  bones 
of  the  face  and  head,  and  so  involve  the  brain,  causing  a  fatal  termina- 
tion. 

Treatment. — The  treatment  of  necrosis  in  general  should  be  that 
of  non-interference,  except  the  opening  of  the  subperiosteal  abscesses, 
and  disinfection,  until  such  time  as  separation  of  the  sequestrum  has 
taken  place.  Nothing  is  to  be  gained  by  surgical  operations  for  the 
removal  of  necrosed  portions  of  bone  before  separation  occurs,  as  it  is 
usually  impossible  to  previously  determine  to  what  extent  the  necrosis 
will  involve  the  bone.  Furthermore,  such  attempts  at  removing  the 
dead  bone  would  be  worse  than  useless,  as  they  would  be  likely  to  ag- 
gravate the  inflammatory  symptoms,  and  make  a  secondary  operation 
necessary.  The  treatment  must  therefore  be  one  of  expectation  and 
conservatism. 

The  establishment  of  free  openings  for  the  discharge  of  the  ac- 
cumulated pus,  and  frequent  irrigation  of  the  suppurating  surfaces  with 
antiseptic  solutions,  is  about  all  that  can  be  done  until  the  sequestrum 
is  loosened.  The  fetid  odor  of  the  breath  and  of  the  discharges  may  be 
corrected  by  the  free  use  of  solutions  of  the  permanganate  of  potas- 
sium and  cinnamon  water.  The  peroxid  of  hydrogen  and  the  medicinal 
pyrozone  are  also  useful  in  the  same  direction,  but  they  should  not  be 
used  in  those  cases  where  there  are  not  free  openings  for  the  escape  of 
the  liberated  gas,  since  it  may  occur  that  the  pressure  of  the  gas  will 
be  so  great  as  to  dissect  a  considerable  area  of  periosteum  from  the 
bone,  beyond  the  original  lesion,  and  by  that  much  increase  the  extent 
of  the  necrosis.    One  such  case  occurred  in  the  practice  of  the  writer, 


272  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

with  the  result  of  making  him  thereafter  extremely  cautious  in  the  use 
of  these  remedies.  The  constitutional  treatment  should  be  supporting 
throughout, — good  food,  milk,  and  concentrated  liquid  foods  are  best 
in  these  cases,  on  account  of  the  inability  of  the  patient  to  use  the  jaws 
for  mastication.  Tonics  are  also  indicated, — iron,  quinin,  inalt  ex- 
tracts, cod-liver  oil,  etc.,  and  change  of  air. 


CHAPTER    XXIX. 

NECROSIS  OF  THE  JAWS  (Continued). 

Exanthematous  Necrosis. — The  eruptive  fevers  are  productive  of 
a  large  percentage  of  the  cases  of  necrosis  of  the  jaws  in  children. 
The  age  limit  in  which  it  is  most  likely  to  occur  is  between  the  third 
and  eighth  years.  It  is  exceedingly  rare  that  a  case  of  necrosis  is  de- 
veloped as  one  of  the  sequelae  of  the  exanthems  outside  of  this  limit. 

It  is  interesting  to  note  the  correspondence  of  the  age  limit  with 
the  period  of  the  greatest  activity  in  the  developmental  processes  of 
the  jaws  and  the  teeth.  The  teeth  are  dermal  appendages,  developed 
from  the  layers  of  the  mucous  membrane;  consequently  these  tissues 
are  more  or  less  susceptible  during  their  development  to  the  same  in- 
fluences which  affect  other  portions  of  the  dermal  skeleton.  The  pecu- 
liar toxic  conditions  of  the  system  which  exist  during  attacks  of  scarlet 
fever,  measles,  and  smallpox  would  seem  to  be  the  exciting  cause  of 
necrosis,  while  the  exceeding  activity  of  the  vascular  system  of  the 
parts  would  predispose  to  congestion  and  inflammation. 

Necrosis  is  more  liable  to  follow  scarlet  fever  than  measles  or 
smallpox.  Salter  places  the  ratio  as  between  scarlet  fever  and  measles 
at  about  three  of  the  former  to  one  of  the  latter;  between  scarlet,  fever 
and  smallpox,  as  about  four  to  one;  and  between  measles  and  small- 
pox, six  to  four. 

The  severity  of  the  attack  seems  to  bear  no  relation  to  the  liability 
to  cause  necrosis.  Mild  cases  develop  necrosis  as  frequently  as  severe 
ones,  and  vice  versa.  Occasionally  the  necrosis  is  associated  with 
other  secondary  symptoms,  but  in  the  majority  of  instances  this  is  the 
only  one,  and  it  would  seem  that  it  had  a  predilection  for  otherwise 
healthy  children. 

Symptoms. — This  form  of  necrosis  first  shows  itself  a  few  weeks 
after  the  attack  of  the  fever;  the  approach  of  the  affection  is  marked 
by  aching  and  soreness  of  the  teeth,  swelling,  tenderness,  and  turges- 
cence  of  the  gums,  and  fetid  breath,  quickly  followed  by  suppuration 
and  all  the  symptoms  of  necrosis. 

Treatment. — The  treatment  is  substantially  the  same  as  that  indi- 
cated for  necrosis  of  the  jaws  in  general.  The  condition  of  the  gen- 
eral health,  however,  should  be  carefully  watched,  and  every  effort 

19  273 


274  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

made  to  improve  it,  by  good  foods,  tonics,  fresh  air,  and  stimulants 
when  required. 

Mercurial  Necrosis. — Mercurial  periostitis  and  necrosis  of  the 
jaws  used  to  be  quite  common  forty  or  fifty  years  ago,  especially  in  the 
southern  portions  of  our  country,  when  mercury  w^as  used  so  ex- 
tensively and  in  such  large  doses.  Happily,  in  these  days  the  more 
intelligent  use  of  the  drug  has  made  such  cases  much  less  common. 

The  loss  of  osseous  tissue  from  mercurial  poisoning  varies  very 
greatly  in  its  extent.  It  may  be  confined  to  the  alveolar  process  sur- 
rounding one  or  two  teeth,  or  extend  throughout  the  entire  alveolar 
process  of  one  or  both  jaws,  or  an  entire  jaw  may  be  lost.  Sometimes 
the  constitutional  effects  may  be  so  overwhelming  as  to  endanger  the 
life  of  the  sufferer,  occasionally  proving  fatal. 

When  the  death  of  the  bone  is  extensive  there  is  often  associated 
with  it,  as  a  complication,  sloughing  of  the  gums  and  of  the  cheeks, 
causing  perforation  of  the  buccal  walls  and  consequent  disfigurement 
of  the  face.  In  other  cases  the  sloughing  is  confined  to  the  mucous 
membrane,  or  it  may  invade  the  muscular  tissue  of  the  cheek  or  lips 
without  perforating  the  integument.  Under  these  circumstances  large 
masses  of  cicatricial  tissue  are  formed  by  the  process  of  healing,  which 
upon  contraction  may  give  rise  to  permanent  closure  of  the  jaws. 

The  writer  has  seen  but  few  cases  of  necrosis  of  the  jaws  that 
could  be  fairly  attributed  to  mercurial  poisoning,  and  two  of  these 
proved  fatal.  The  first  was  a  railroad  engineer,  forty  years  of  age. 
Large  doses  of  mercury  were  admiiiistered  by  his  physician  during  an 
attack  of  malarial  fever,  with  the  result  of  producing  severe  ptyalism, 
with  a  profuse  flow  of  saliva,  three  to  four  pints  per  day,  and  extensive 
stomatitis,  periostitis,  and  necrosis  of  both  the  upper  and  lower  jaws. 
All  of  the  teeth  in  both  jaws  became  so  loose  that  most  of  them  were 
removed  with  the  fingers;  the  rest  were  extracted  with  the  forceps. 
Suppuration  was  very  extensive  in  both  jaws,  pus  discharging  into  the 
mouth  in  large  quantities,  and  through  several  sinuses  under  the  lower 
jaw.  The  patient  rapidly  failed,  and  died  before  separation  of  the 
sequestra  had  taken  place.  This  was  an  exceptionally  severe  case,  and 
fortunately  an  uncommon  one. 

The  second  fatal  case  was  quite  recently  under  observation.  The 
patient  was  an  Italian  woman  about  thirty  years  of  age,  who  was  suf- 
fering from  mercurial  periostitis  and  necrosis  of  the  superior  and  in- 
ferior maxillse,  and  gave  a  history  of  having  taken  only  fifteen  grains 
of  calomel  in  three-grain  doses  "at  bedtime."  The  necrosis  was  ac- 
companied with  extensive  sloughing  of  the  gums  of  the  inferior  maxilla 
and  the  soft  tissues  covering  the  hard  palate,  swollen  tongue,  fetid 
breath,  excessive  salivary  secretion,  loosened  teeth,  and  an  uncontrol- 
lable diarrhea.     Death  was  from  exhaustion. 


NECROSIS    OF    THE   JAWS.  275 

Treatment. — The  treatment  has  been  already  described  under  the 
head  of  mercurial  periostitis.  The  rules  governing  the  removal  of  the 
sequestra  are  the  same  as  those  for  necrosis  in  general. 

Arsenical  Necrosis. — Necrosis  of  the  alveolar  process  is  not  an 
uncommon  result  of  the  careless  application  of  arsenious  acid  for  the 
devitalization  of  the  tooth-pulp;  or  from  accidental  causes,  like  the 
penetration  of  the  drug  beyond  the  apical  foramen;  or  through  the 
minute  canals  which  sometimes  exist  in  the  sides  of  the  roots  of  the 
teeth,  and  which  communicate  with  the  root-canal  and  the  pericemen- 
tum. Accidents  more  often  occur  in  the  treatment  of  the  teeth  of  chil- 
dren, for  the  deciduous  teeth  have  large  apical  foramina;  consequently, 
the  use  of  arsenic  for  pulp-devitalization  in  these  cases  is  dangerous  in 
the  extreme.  The  same  is  true  of  all  the  permanent  teeth  during  the 
development  of  their  roots,  which  are  not  completed  until  some  consid- 
erable time  after  the  eruption  of  the  crown.  The  first  permanent 
molars  most  often  require  the  devitalization  of  the  pulp  as  a  result  of 
caries,  but  as  they  are  not  fully  developed  until  about  the  end  of  the 
tenth  year,  it  would  be  dangerous  to  apply  arsenic  for  this  purpose 
before  that  time.  This  rule  should  apply  to  all  the  teeth  of  young 
people  during  the  development  of  these  organs. 

Arsenious  acid  is  a  powerful  escharotic,  but  at  the  same  time  a 
valuable  remedy  when  carefully  used.  The  faults  in  applying  arsenic 
to  the  tooth-pulp  for  the  purpose  of  devitalizing  it,  lie  in  two  direc- 
tions : 

First,  too  large  a  quantity  is  generally  used;  and, 
Second,  it  is  not  properly  sealed  in  the  cavity.  The  one-hundredth 
of  a  grain  of  arsenic  is  just  as  effective  in  destroying  a  pulp  as  a  larger 
quantity  would  be.  This  amount  may  be  safely  left  in  the  adult  tooth 
from  two  to  three  days,  when  properly  sealed  in  the  cavity;  in  fact, 
it  will  require  about  this  length  of  time  to  effectually  destroy  the  vital- 
ity. The  only  safe  method  of  sealing  a  cavity  in  which  arsenic  has 
been  placed  is  with  the  oxyphosphate  cement.  Gutta-percha,  the  tem- 
porary stoppings,  and  cotton  and  sandarac  varnish  cannot  hermetically 
seal  a  cavity,  and  anything  less  than  this  is  dangerous. 

In  arsenical  necrosis  the  disease  rarely,  if  ever,  extends  beyond  a 
fragment  of  the  alveolar  process  involving  one  or  two  teeth,  with  the 
possible  loss  of  the  teeth  involved  in  the  death  of  this  portion  of  the 
bone.  It  oftener  occurs,  however,  that  the  necrosis  does  not  extend 
beyond  a  portion  of  the  alveolar  process  upon  that  side  of  the  tooth 
on  which  the  arsenic  came  in  contact  with  the  soft  tissue.  These  acci- 
dents occur  more  frequently  in  applying  the  drug  to  teeth  having 
cavities  upon  their  approximal  and  buccal  surfaces  near  the  gingival 
"borders;  consequently,  the  alveolar  septi  and  the  outer  plate  of  the 
alveolar  process  are  the  most  common  locations  of  necrosis  from  this 


276  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

cause.  The  soft  tissue  with  which  the  drug  comes  in  contact  is  always 
devitahzed  and  slouglis  away. 

Treatment. — The  treatment  of  necrosis  from  the  effects  of  arseni- 
otis  acid  does  not  materially  differ  from  that  of  necrosis  from  other 
causes.  The  application  of  the  hydrated  oxid  of  iron — sesquioxid — to 
the  injured  tissues  is  advocated  very  strongly  by  some  authorities.  To 
the  writer  the  local  application  seems  of  little  value,  except  to  serve  as 
an  antidote  for  that  which  still  remains  in  the  tissues  of  the  tooth. 

Phosphorus  Necrosis. — ^Maxillary  necrosis,  the  result  of  poisoning 
from  the  fumes  of  phosphorus,  was  at  one  time  a  very  common  aiTec- 
tion  among  the  operatives  in  match  factories.  It  was  so  terrible  in 
its  results  that  it  became  the  subject  several  times  of  legislative  inquiry 
in  England  and  other  European  countries,  with  the  desire  of  discover- 
ing some  means  of  preventing  or  mitigating  its  ravages.  Scientific  in- 
vestigation was  also  instituted  by  medical  men  as  to  the  cause  of  the 
disease,  and  to  discover,  if  possible,  some  means  of  prevention,  with  the 
result  of  establishing  beyond  a  reasonable  doubt  these  facts:  First, 
That  the  affection  was  caused  by  the  fumes  of  phosphorus,  but  that 
it  must  gain  access  to  the  periosteum  of  the  bone  in  order  to  establish 
the  disease.  Second,  That  in  every  case  of  necrosis  of  the  jaws  from 
this  cause,  the  disease  originated  in  connection  with  a  carious  tooth, 
and,  on  the  other  hand,  operatives  with  sound  teeth  were  entirely  ex- 
empt from  it.  This  seemed  to  indicate  that  the  phosphorus  gained 
access  to  the  periosteum  through  the  tooth-pulp,  and  thus  established 
the  affection.  The  disease  appeared,  therefore,  to  be  one  of  local 
poisoning,  and  the  fact  that  the  other  bones  of  the  body  escaped  the 
disease  added  strength  to  the  argument. 

Opposed  to  this  view  are  Langenbeck  and  others,  who  maintain 
that  the  eft'ects  of  the  poison  were  produced  through  the  system,  the 
same  as  with  mercury.  There  seems  to  be  no  fact  in  pathology  better 
established  than  that  the  disease  is  the  result  of  local  poisoning,  pro- 
duced through  some  break  in  the  continuity  of  the  structures  of  the 
mouth,  which  permits  the  poisonous  fumes  to  come  in  contact  with 
the  periosteum. 

Precautionary  measures  were  therefore  adopted  by  the  manufac- 
turers, as  a  result  of  the  scientific  investigation,  for  the  protection  of 
their  employes,  which  have  proved  so  efficacious  that  now  the  disease 
is  rarely  seen.  These  means  consisted  of  thorough  ventilation  of  the 
dipping  rooms,  cleanliness  of  the  factories,  with  a  proper  care  and 
treatment  of  the  teeth  of  the  operators,  and  teaching  them  habits  of 
personal  cleanliness.  The  disease  has  occasionally  been  contracted  by 
children  from  the  chewing  of  the  dipped  ends  of  matches. 

Symptoms. — Phosphorus  necrosis  is  very  insidious  in  its  first  ap- 
proach, the  symptoms  being  so  mild  as  scarcely  to  be  noticed,  usually 


NECROSIS    OF   THE    JAWS.  277 

beginning-  in  a  supposed  toothache.  As  the  disease  progresses,  the 
symptoms  become  marked  and  aggravated;  the  pain  in  the  jaw  is 
excruciating  in  the  extreme,  the  swelHng  very  great,  often  extending 
over  the  entire  side  of  the  face  and  head.  Abscesses  form  and  open 
upon  the  external  surfaces,  and  also  into  the  mouth,  forming  sinuses 
through  which  the  dead  bone  can  be  felt  with  a  probe.  The  opening 
of  the  abscesses  usually  affords  great  rehef;  the  pus  is  very  of=fensive, 
and  usually  profuse.  The  health  of  the  patient  often  deteriorates  very 
rapidly  from  inability  to  take  food,  and  from  the  disturbance  of  the 
stomach  induced  by  the  unavoidable  swallowing  of  considerable  quan- 
tities of  the  fetid  discharges.  When  the  necrosis  is  extensive,  the  con- 
stitutional disturbance  is  correspondingly  great.  Death  frequently 
occurs  from  exhaustion.  A  peculiar  and  characteristic  feature  of  phos- 
phorus necrosis  is  the  pumice-like  deposit  upon  the  sequestrum. 

Trcafmcnt.— The  treatment  consists  of  sustaining  the  vital  powers 
of  the  patient  by  the  administration  of  concentrated  liquid  food,  tonics, 
and  stimulants.     The  local  treatment  is  that  of  necrosis  in  general.^ 

Syphilitic  Necrosis.— The  manifestations  of  syphilis  in  the  jaws 
are  generally  associated  with  the  tertiary  stage  of  the  disease,  the 
earlier  lesions  being  rarely  met  with  in  this  region.  The  upper  jaw  is 
much  oftener  affected  than  the  lower.  When  the  disease  attacks  the 
lower  maxilla,  it  is  usually  confined  to  the  alveolar  process,  though  it 
sometimes  extends  to  the  body  of  the  bone.  In  the  upper  maxilla  it 
attacks  the  alveolar  and  palatine  processes  and  the  palate  bones  most 
frequently;  its  most  common  site  is  the  central  part  of  the  dome  of  the 
hard  palate  (Fig.  117),  but  it  is  not  always  confined  to  these  locations. 
The  writer  recently  saw  a  case  in  an  old  soldier  in  which  the  palate 
bones,  the  bones  of  the  nose,  and  nearly  the  entire  upper  jaw,  had  been 
destroyed  by  the  disease;  the  only  portions  of  the  jaw  that  remained 
were. the  orbital  plate  and  malar  processes,  and  a  portion  of  the  outer 
walls  of  the  antra.  The  soft  palate  was  intact.  The  opening  into  the 
nose  was  bounded  posteriorly  by  the  soft  palate,  laterally  and  anteriorly 
by  the  cheeks  and  lips  only,  except  that  portion  of  the  outer  wall  of  the 
antra  just  referred  to.  The  opening  measured  antero-posteriorly  one 
and  three-fourths  inch,  and  from  side  to  side  one  and  one-half  inch. 
The  destruction  of  the  osseous  tissue  of  the  nose  and  jaws  is  rarely  so 
appalling  as  in  this  case. 

The  tertiary  symptoms  of  syphilis  frequently  present  themselves 
long  after  the  primary  and  secondary  symptoms  have  disappeared, 
while  the  natural  reticence  of  the  patient  to  admit  early  indiscretion 
often  makes  the  diagnosis  extremely  difficult,  so  that  for  lack  of  posi- 
tive evidence  many  cases  are  excluded  from  the  category  which  no 
doubt  properly  belong  there. 

The  syphiHtic  virus  has  a  predilection  for  the  compact  tissue  of 


278 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


the  bone,  and  most  often  attacks  those  portions  of  the  bone  which 
have  soft,  thin  coverings,  like  the  bones  of  the  skull,  the  palate  pro- 
cess, the  palate  bones,  and  the  alveolar  processes.  A  marked  exception 
to  this  is  the  necrosis  of  the  spongy  bones  of  the  nose,  following  syphil- 
itic ulceration  of  the  nasal  mucous  membrane. 

Symptoms.- — Syphilitic  periostitis  of  a  marked  type,  or  ulceration, 
always  precedes  death  of  the  bone  in  the  region  of  the  mouth  and  nose. 
This  form  of  the  disease  is,  however,  much  less  rapid  in  its  work  of  de- 
struction than  that  form  caused  by  the  toxic  influence  of  the  eruptive 
fevers. 

In  syphilitic  necrosis,  on  account  of  the  slower  progress  or  chronic 
condition  of  the  disease,  and  frequent  exacerbations  in  the  inflamma- 
tory process,  death  of  the  bone  frequently  occurs  in  such  a  way  as  to 

Fig.  117. 


Syphilitic  Perforation  of  the  Hard  or  Bony  Palate. 


form  numerous  sequestra.  Surgical  interference  before  active  inflam- 
mation has  entirely  subsided  is  often  responsible  for  a  renewal  of  the 
inflammatory  symptoms,  and  extension  of  the  necrotic  process. 

It  has  been  the  fortune  of  the  writer  in  his  hospital  service  to  en- 
counter a  goodly  number  of  cases  of  syphilitic  necrosis  of  the  jaws,  the 
great  majority  of  which  have  been  associated  with  the  vault  of  the 
mouth  and  the  alveolar  process  of  the  upper  jaw.  Among  these  might 
be  mentioned,  by  way  of  illustration,  the  case  of  a  young  lawyer,  thirty 
years  of  age,  who  had  contracted  syphilis  seven  years  before,  and  for 
whom  was  removed  a  sequestrum  of  bone  involving  the  median  half  of 
the  alveoli  of  the  central  incisor  teeth,  and  the  floor  of  the  nasal  fossa, 
to  the  extent  of  about  half  an  inch  in  diameter,  leaving  an  opening 
under  the  lip  into  the  nasal  fossa.       This  opening  was  successfully 


NECROSIS    OF    THE    JAWS.  279 

closed,  and  the  teeth  became  reattached  by  the  aid  of  sponge-g^rafts. 
This  operation  was  made  thirteen  years  ago,  and  the  teeth  are  still  firm 
and,  to  all  appearances,  in  a  normal  condition. 

Another  case,  a  man  forty-five  years  of  age,  contracted  syphilis 
at  the  age  of  twenty,  had  been  married  sixteen  years,  and  had  three 
healthy  children.  Necrosis  of  the  right  superior  maxilla  developed 
three  months  before  his  first  visit.  A  sequestrum  of  bone  was  later 
removed  for  him,  involving  the  alveolar  process  from  the  lateral  incisor 
to  the  tuberosity,  including  the  entire  floor  of  the  antrum. 

Another,  a  young  man  twenty-six  years  old,  had  contracted  the 
disease  about  five  years  before.  His  present  trouble  had  developed 
about  four  months  previous  to  his  admission  to  the  hospital.  In  this 
case  there  was  extensive  necrosis  of  the  palate  process  and  palate 
bones.  Several  sequestra  were  removed  at  various  times,  which  left 
an  opening  in  the  hard  palate  the  size  of  a  silver  half-dollar. 

A  very  recent  case  is  that  of  a  little  girl,  nine  years  old,  suffering 
from  congenital  syphilis,  with  extensive  necrosis  of  the  bones  of  the 
nose  and  palate  process.  Later  the  nasal  septum,  portions  of  the  tur- 
binated bones  and  the  hard  palate  were  lost  by  the  disease. 

The  sequestra  in  syphilitic  necrosis  are  frequently  coated  with  a 
gray-black  deposit,  something  like  that  found  in  phosphorus  necrosis. 

Treatment. — Mercury  in  the  form  of  the  protiodid,  biniodid,  bi- 
chlorid,  calomel,  gray  powder,  blue  mass,  and  other  combinations  of 
the  metal  are  counted  among  the  most  efiicacious  drugs  in  the  treat- 
ment of  syphilis  in  its  earlier  stages.  The  protiodid  is  the  most  popu- 
lar with  the  profession,  and  is  administered  in  doses  of  one-fifth  of  a 
grain  three  times  per  day.  In  the  tertiary  stage  of  the  disease,  espe- 
cially in  the  bone-afifections,  mercury  in  any  of  its  forms  is  generally 
considered  to  be  inadmissible. 

The  iodid  of  potassium  is  more  generally  used  in  the  tertiary  stage 
of  the  disease  than  any  other  drug.  It  is  administered  in  doses  of  from 
three  grains  to  twenty,  dissolved  in  distilled  water,  milk,  cinnamon 
water,  syrup  of  sarsaparilla,  or  any  of  the  various  syrups  used  as 
vehicles  by  the  druggists.  The  iodid  of  potassium  gives  the  happiest 
results  in  the  treatment  of  syphilitic  bone-diseases.  The  larger  doses 
of  the  drug,  viz :  two  drachms  to  one-half  ounce,  in  twenty-four  hours, 
are  sometimes  administered,  but  are  not  generally  indicated  in  this 
form  of  the  affection. 

In  those  cases  in  which  the  necrosis  is  very  extensive  and  the  vital 
powers  are  much  depressed,  it  is  better  to  withdraw  the  drug  alto- 
gether, and  substitute  tonics. 

Especial  attention  should  be  given  in  all  cases  to  the  general  build- 
ing up  of  the  vital  forces.  The  diet  should  be  plentiful  and  nutritious. 
Alcohol  should  be  administered  in  moderation,  if  at  all,  for  its  tonic, 


28o  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

not  for  its  stimulating  effects.  Tobacco  should  be  excluded  in  all  its 
forms.  The  body  should  be  kept  scrupulously  clean  by  daily  sponge 
baths  with  tepid  water,  and  covered  with  warm  clothing. 

The  mind  and  body  should  be  kept  employed  with  the  customary 
duties,  care  being  taken  not  to  overtax  the  mental  and  physical  powers. 

In  the  severer  cases,  change  of  climatCj  such  as  a  sea  voyage  or  a 
few  months'  residence  at  the  seashore  in  the  summer  season,  or  a  trip 
South  in  the  cold  months,  is  to  be  advised. 

The  tonics  which  may  be  administered  with  benefit  are  iron,  cod- 
liver  oil,  quinin;  the  bitter  tonics,  coca  wine,  etc. 

Reproduction  of  Bone. — The  bones  in  general  have  a  very  marked 
power  of  regeneration.  The  seat  of  this  power  lies  in  great  measure 
in  the  periosteum,  and  in  a  less  degree  in  the  medullary  tissue.  In 
many  cases  the  periosteum  alone  performs  the  office  of  reproducing  the 
bone. 

The  knowledge  of  these  facts  has  brought  about  the  most  con- 
servative treatment  upon  the  part  of  the  surgeon  in  all  operations  upon 
the  bones,  that  no  more  of  the  periosteum  be  sacrificed  than  is  neces- 
sary to  insure  the  success  of  the  treatment  for  which  the  operative  pro- 
cedure was  instituted, 

Malgaigne  was  the  first  to  recognize  the  importance  of  conserv- 
ing the  periosteum  for  the  purpose  of  establishing  the  process  of  re- 
generation of  bone. 

Oilier  demonstrated  the  possibility  of  transplanting  the  periosteum 
for  the  purpose  of  reproducing  bone  in  locations  where  the  original 
bone  and  periosteum  had  been  lost. 

Reproduction  of  osseous  tissue  is  a  frequent  occurrence  follow- 
ing fractures,  gunshot  wounds,  and  amputations;  more  rarely  after 
trephining  and  resections,  after  extirpation  of  bones  and  following 
necrosis.  In  all  of  these  conditions  there  is  a  more  or  less  incomplete 
or  a  complete  reproduction  of  the  bone.  Regeneration  of  entire  bones 
is  rare.  Wagner  mentions  the  case  of  a  woman  in  whom  an  entire 
new  clavicle  was  formed  following  necrosis.  Several  cases  of  reproduc- 
tion of  nearly  the  entire  lower  jaw  have  been  recorded,  and  numerous 
cases  of  regeneration  of  considerable  portions. 

The  writer  has  reported  two  cases  of  regeneration  of  the  ascend- 
ing ramus  with  perfect  mobility  of  the  temporo-maxillary  joint.  The 
first  was  in  a  girl  sixteen  years  of  age,  suffering  from  dentigerous  cyst 
of  the  lower  jaw,  the  result  of  an  inverted  third  molar  tooth,  and 
necrosis  of  the  ramus,  including  the  head  of  the  condyle,  which  was 
removed  (Fig.  ii8).  One  year  afterward  the  restoration  was  so  com- 
plete in  all  respects  as  to  make  it  seem  impossible  that  so  extensive  a 
loss  of  tissue  had  occurred.  The  other  was  in  a  boy  five  years  of  age — • 
already  referred  to — who  lost  the  ramus  and  body  of  the  jaw  behind 


NECROSIS    OF    THE    JAWS.  281 

the  second  deciduous  molar  from  scarlet  fever.  In  this  case  also  there 
was  a  complete  restoration  of  the  lost  bone  and  perfect  mobility  of  the 
joint. 

The  process  of  regeneration  or  repair  after  loss  of  the  jaw  from 
necrosis  dififers  greatly  in  the  upper  and  the  lower  maxillae.  In  the 
upper  jaw  it  is  very  rarely  that  true  bone  is  reproduced,  but  instead 
there  is  developed  a  hard,  fibrous  tissue,  which  fills  the  gap  and  serves 
the  purpose  of  bone.  This  often  occurs  in  children  who  have  suffered 
from  exanthematous  necrosis,  but  rarely  in  adults,  except  by  the  aid 
of  sponge-grafting. 

In  the  lower  jaw  regeneration  of  bone  after  necrosis  is  the  general 
result,  but  it  is  claimed  by  some  authors  that  resorption  of  the  new 
bone  sometimes  takes  place — occasionally  after  a  considerable  period 

Fig.  118. 


Condyle  of  Inferior  Maxilla  with  misplaced  and  inverted  Third  Molar. 

— in  those  cases  where  the  entire  body  of  the  jaw  has  been  reproduced, 
so  that  finally  there  is  scarcely  enough  bone  left  to  keep  out  the  lower 
lip  and  the  chin,  and  this  feature  of  the  face  is  completely  obliterated. 

A  case  of  this  character,  a  young  lady,  recently  under  the  care  of 
the  writer,  for  whom  he  has  attempted  the  restoration  of  the  contour 
•of  the  face  by  a  plastic  operation  and  the  construction  of  an  appliance 
to  represent  the  body  of  the  jaw,  upon  which  are  mounted  artificial 
teeth.  This  appliance  is  being  worn  with  considerable  comfort;  the 
effort  has  greatly  improved  the  contour  of  the  lower  part  of  the  face, 
and  bids  fair  to  be  a  tolerable  success. 

The  cause  of  this  resorption  does  not  seem  to  be  understood. 
Salter  suggests  that  the  resorption  of  the  new  jaw  might  possibly  be 
prevented  by  inserting  a  plate  of  artificial  teeth,  and  thus  supply  it  with 
a  definite  function. 


CHAPTER    XXX. 

STOMATITIS. 

Definition. — Stomatitis  (Gr.  a-zoiw.,  mouth,  and  ;r;o,  the  ending  used 
to  designate  inflammation). 

Stomatitis  is  an  inflammation  of  the  mucous  membrane  of  the 
cavity  of  the  mouth.  All  inflammatory  conditions  which  involve  the 
gums,  the  inner  surface  of  the  cheeks,  the  lips,  and  the  tongue  are  in- 
cluded under  the  term  stomatitis. 

The  affections  which  are  thus  included  are  with  few  exceptions 
confined  to  infancy  and  childhood.  Adults  seldom  suffer  from  these 
affections  except  as  a  manifestation  of  some  other  morbid  condition. 

A  clinical  study  of  the  inflammatory  affections  of  the  mucous 
membrane  of  the  mouth  will  reveal  a  close  resemblance  in  certain  fea- 
tures to  the  inflammatory  affections  as  they  appear  in  the  skin;  while 
in  other  points  they  will  present  features  which  are  comm.on  to  inflam- 
matory conditions  of  the  mucous  membrane  in  general.  It  is  fre- 
quently noticed  that  "in  measles  a  spotty  or  macular  eruption  appears 
upon  the  oral  mucous  membrane,  and  in  scarlatina  a  punctate  or  diffuse 
scarlet  eruption,"  while  "in  smallpox,  chicken-pox,  herpes,  pemphigus, 
and  in  foot-and-mouth  disease," — an  infection  from  cattle, — "there 
are  eruptions  of  vesicles  and  pustules,  which  pass  through  the  same 
stages  as  those  of  the  skin"  (Ziegler). 

Erysipelas  of  the  face  not  infrequently  presents  an  inflamed  condi- 
tion of  the  oral  and  nasal  mucous  membrane,  while  syphilis  and  scurvy 
are  accompanied  by  characteristic  mouth-affections. 

Diphtheria  is  not  always  confined  to  the  tonsils,  pharynx,  uvula, 
and  velum  palati,  but  may  likewise  involve  the  mouth.  Certain  drugs, 
also,  such  as  mercury  and  iodin,  and  the  mineral  acids,  often  produce 
inflammatory  conditions  of  the  oral  mucous  membrane. 

The  forms  of  inflammation  of  the  mouth  which  are  most  common 
are' stomatitis  simplex,  stomatitis  catarrhalis,  stomatitis  aphthosa,  stoma- 
titis parasitica,  and  stomatitis  ulcerosa. 

From  the  time  of  Hippocrates  to  the  present  day,  it  has  been  the 

custom  of  some  authorities  to  class  all  forms  of  inflammation  of  the 

mouth  that  are  characterized  by  white  patches,  as  aphthae;  while  others 

have  included  all  those  forms  which  present  ulcerated  patches  not 

282 


STOMATITIS.  283 

specific,  and  the  more  serious  phagedenic  conditions,  as  different  de- 
grees of  the  same  affection.  ,        ,      ,  ^„a 
At  the  present  time  the  distinctions  are  more  sharply  drawn,  and 
the  classification  based  upon  the  etiology  and  pathology  of  these  affec- 
tions     Stomatitis  with  white  patches  is  now  divided  mto  two  distmct 
forms:  stomatitis  aphthosa  and  stomatitis  parasitica,  the  former  bemg 
due  to  a  follicular  inflammation  with  exudation  or  false  membrane, 
and  the  latter  to  the  action  of  a  specific  fungus  which  grows  mto  the 
squamous  layer  of  the  mucous  membrane,  ^hese,  to  the  unaided  eye 
are  readily  mistaken  one  for  the  other,  the  only  observable  difference 
being  the  smaller  size  of  the  patches  in  stomatitis  parasitica   and  the 
tendencv  of  the  patches  in  stomatitis  aphthosa  to  spread,  and  m  some 
Instanced  to  become   confluent.     The   microscope   and  bactenologic 
cultures  are  necessary  to  arrive  at  a  positive  diagnosis 

Stomatitis  Simplex.-This  form  of  the  disease  is  the  mildest  of 
the  inflammatory  affections  of  the  mouth,  and  is  generally  expressed  in 
a  'more  or  less  intense  redness  of  the  surface"  of  the  mucous  mem- 
brane of  the  cheeks,  the  lips,  and  the  gums,  which  is  ^ue  to  localized 
hyperemia.  It  is  usually  found  in  infants  and  young  children,  and 
associated  with  some  form  of  gastric  or  intestinal  derangement.  As  a 
rule  it  is  of  short  duration,  and  rapidly  disappears,  but  occasionally  it 
persists  and  gradually  passes  into  a  severe  type  of  the  disease  known  as 

stomatitis  catarrhalis.  t„„,*;ti. 

Sy,„m,us.-The  disease   is  sometimes  designated  as  stoma  .t.s 
eryther^a  from  its  resen.blance  to  erytl^ema  of  tlte  skin     The  a£Eect.on 
s"cl!lracterized  by  tl,e  appearance  of  rose-red,  ^'^^'^^^tZ'^'Z 
the  surfaee  of  the  mucous  membrane  of  the  mouth,  usually  upon  the 
cheeks  and  the  lips,  but  occasionally  also  upon  the  gums,  the  palate, 
and  the  velum.     Like  erythema  simplex  of  the  skm    .t  appears  sud- 
denly, lasts  for  a  few  hours  or  two  or  three  days,  and  as  rapidly  sub- 
sides    The  bright  color  of  the  patches  may  be  made  to  disappear  by 
pressure  upon  them,  but  the  color  immediately  returns  upon  removing 
the  pressure.     Hea    and  dryness  of  the  mouth  are  often  promment 
symptoms,  while  in  other  cases  the  salivary  glands  are  sometimes  very 
active  and  the  saliva  dribbles  from  the  mouth.     (Day.) 

There  may  be,  and  often  is  a  rise  in  the  body  temperature   and 
other  febrile  symptoms  accompanying  the  appearance  of  the  erythema 
but  tWs  in  all  probability  is  due  to  the  constitutional  disorder  of  wh    h 
it  is  symptomatic.     Restlessness,  flatulency,  and  diarrhea  are  often 

^™t:rrTr  treatment  of  this  affection  is  to  be  directed  to 

the  constitutional  condition  upon  which  it  is  dependent,  and  of  which  it 

sbuta  local  expression.    The  erythema  usually  subsides  as  soon  as 

he  constitutional  disorder  is  corrected.     This  in  many  instances  may 


284  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

be  accomplished  by  the  administration  of  a  mild  cathartic  and  the  regu- 
lation of  the  diet. 

Stomatitis  Catarrhalis. — This  affection  is  often  a  symptomatic  ex- 
pression of  a  more  grave  constitutional  malady,  though  it  may  be  an 
entirely  local  disease  induced  by  irritation  from  erupting  teeth,  or  the 
taking  into  the  mouth  of  irritating  substances.  The  disease  is  often 
preceded  by  the  simple  erythematous  condition  just  described,  and  it 
appears  as  a  generally  uniform  diffuse  inflammation,  spreading  over 
the  cheeks,  lips,  and  gums,  and  upon  the  hard  palate  as  "streaks  and 
patches."  The  papillae  of  the  tongue  are  most  affected  (Ziegler),  many 
of  them  appearing  as  prominent  tubercles.  The  mucous  glands  be- 
come swollen  and  prominent,  so  that  they  can  be  readily  felt  by  passing 
the  finger  over  the  surface  of  the  membrane.  As  the  inflammation 
progresses,  the  mucous  follicles  become  enlarged,  "giving  rise  to  gray- 
ish or  grayish-red  elevations  of  the  surface  surrounded  by  a  reddened 
areola"  (Ziegler).  Occasionally  tiny  cysts  are  developed  as  a  result  of 
the  plugging  of  the  excretory  ducts  of  the  follicles  with  mucoid  cells 
and  the  retention  of  the  secretions.  Sometimes  cracks  and  fissures  will 
appear  upon  the  lips  and  at  the  angles  of  the  mouth,  with  exudation 
and  the  formation  of  crusts. 

The  disease  is  most  common  among  the  children  of  the  very  poor, 
during  the  first  year  of  infantile  life,  and  is  usually  associated  with  bad 
food  and  unsanitary  surroundings.  It  is  rarely  seen  among  the  infants 
of  the  better  classes  of  society,  "unless  the  nipples  of  the  nurse  are  sore 
or  the  milk  is  faulty"  (Day),  or  in  the  bottle-fed  children  when  the 
nurse  allows  the  bottles  and  tubes  to  become  foul. 

Causes. — The  causes  are  gastro-intestinal  disorders,  unwholesome 
food,  uncleanliness,  and  the  nervous  irritation  induced  by  the  eruption 
of  the  deciduous  teeth.  It  is  occasionally  "the  result  of  taking  cold, 
the  inflammation  being  an  extension  of  the  inflammatory  conditions  of 
the  mucous  membrane  of  the  respiratory  tract"  (Swift). 

Symptoms. — The  local  symptoms  are  redness  and  capillary  con- 
gestion of  the  mucous  membrane  of  the  mouth,  accompanied  by  en- 
gorgement and  swelling  of  the  mucous  follicles ;  swelling  of  the  tongue, 
lips,  cheeks,  and  gums;  fetor  of  the  breath;  heat  and  dryness  of  the 
mouth,  followed  in  some  cases  by  an  excessive  secretion  of  the  saliva 
and  mucus,  especially  in  children  who  are  teething.  In  the  latter  cases 
the  gums  are  often  soft  and  spongy,  and  bleed  under  the  slightest  pro- 
vocation. Vesicles  and  blebs  are  sometimes  found  upon  the  tongue, 
lipSj  and  cheeks,  which  when  ruptured  leave  minute  ulcers  "having  a 
yellowish  patch  of  lymph  in  the  center,  with  a  red  margin"  (Day).  Fis- 
sures form  at  the  angles  of  the  mouth,  and  upon  the  lips,  with  exuda- 
tion and  the  formation  of  crusts.  Pain  in  this  form  of  the  disease  is 
seldom  very  great,  and  the  ulcerations  are  small  and  rarely  trouble- 
some. 


STOMATITIS.  285 

The  constitutional  symptoms  are  febrile  disturbances,  diarrhea^ 
thirst,  loss  of  appetite,  and  sleeplessness.     The  prognosis  is  favorable. 

Treatment. — The  treatment  consists  in  correcting  the  gastro-intes- 
tinal  derangement  by  appropriate  remedies,  such  as  a  dose  of  castor 
oil,  or  a  powder  of  rhubarb  combined  with  carbonate  of  soda  (Day). 
The  milk  should  be  inspected,  and  if  found  unwholesome  changed 
for  that  which  is  good.  The  breasts  of  the  nurse  should  be  exam- 
ined, and  if  the  nipples  are  found  sore  the  child  should  be  fed  with 
the  spoon  or  bottle.  In  the  bottle-fed  children  the  feeding  utensils 
should  be  critically  inspected,  for  many  times  the  disease  may  be 
traced  to  unclean  bottles,  tubes,  and  nipples.  The  irritation  to  the 
gums  from  an  advancing  tooth  is  often  relieved  by  lancing.  The 
mouth  should  be  cleansed  after  each  feeding,  by  means  of  a  piece  of 
gauze  or  absorbent  cotton  wrapped  about  the  finger  or  a  probe,  and 
dipped  in  a  mild  antiseptic  solution,  followed  by  washing  the  mouth 
with  a  chlorate  of  potassium  solution,  or  "an  astringent  lotion  in  the 
form  of  a  weak  solution  of  the  sulfate  of  zinc  or  of  copper"  (Swift). 
Lime-water  should  be  added  to  the  milk,  and  every  effort  made  to  keep 
the  food  and  the  surroundings  of  the  child  in  a  hygienic  condition. 

Stomatitis  Aphtliosa. —  (Gr.    acf^Oa,  an  eruption). 

This  disease — known  as  Canker  sore-mouth- — is  considered  by 
Ziegler  to  be  a  peculiar  form  of  catarrhal  stomatitis,  for  the  reason  that 
the  aphthous  patches  occur  upon  the  oral  mucous  membrane  while 
in  a  catarrhal  condition.  Aphthous  stomatitis  may  be  considered  as  a 
severer  form  of  catarrhal  stomatitis.  The  disease  is  most  common 
among  sickly  children  during  first  dentition,  but  it  is  frequently  seen 
during  second  dentition,  and  occasionally  later  in  life  in  those  who  are 
debilitated  from  illness  or  debauchery,  and  "in  women  during  men- 
struation, in  pregnancy,  and  during  the  puerperal  period."  (Ziegler.) 
It  is  sometimes  associated  with  pneumonia,  gastric  and  intestinal  ca- 
tarrh, bronchitis,  diphtheria,  exanthematous  diseases,  ague,  whooping 
cough,  and  tonsillitis. 

Bohn  has  compared  aphthous  stomatitis  with  impetiginous  eczema 
of  the  skin,  which  appears  in  the  form  of  "an  eruption  consisting  of 
pustules  of  the  size  of  a  pea,  and  drying  into  scabs  without  rupturing." 

Aphthous  stomatitis  is  characterized  by  the  appearance  upon  the 
mucous  membrane  of  small  whitish  or  slightly  yellowish  patches  from 
the  size  of  a  hemp-seed  to  that  of  a  split  pea  (Ziegler).  These 
patches  may  appear  singly  or  in  groups,  and  are  most  abundant  upon 
the  edges  of  the  tongue  and  at  the  gingivo-buccal  fold  of  the  lips  and 
the  cheeks.  Each  patch  is  surrounded  by  a  more  or  less  inflamed 
zone;  they  are  inclined  to  spread  and  coalesce,  forming  liarger  patches 
or  streaks,  though  they  never  reach  any  considerable  size.  "The  erup- 
tion occurs  in  successive  crops,  and  may  thus  be  kept  up  for  weeks." 


286  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

Bohn  found  the  aphthous  patches  "to  consist  of  a  soHd  fibrinous 
exudate  lying  between  the  fibrous  tissue  and  the  epitheHum."  Some- 
times the  inflammation  does  not  extend  beyond  the  formation  of  the 
exudate;  resorption  then  takes  place,  and  the  aphthous  patches  disap- 
pear by  resolution.  The  more  common  termination  is  for  the  epithelial 
covering  to  be  lost,  thus  exposing  the  fibrinous  exudate,  which  is  grad- 
ually separated  from  its  base  and  thrown  off  by  the  regeneration  of  the 
epithelium  which  advances  from  the  margins  and  extends  beneath  the 
exudate.  As  a  result  of  the  simultaneous  reproduction  of  the  epithel- 
ium with  the  extension  of  the  exudate  there  is  rarely  the  formation  of 
what  might  be  termed  a  true  ulcerated  surface.  The  exudate  is  easily 
removed  and  comes  away  in  the  form  of  a  thin,  dirty-yellow  slough, 
leaving  behind  a  livid  base.  Occasionally  the  inflamed  zone  which  sur- 
rounds the  aphthous  patch  becomes  infected  with  the  pus-microbes, 
and  suppuration  results. 

Causes. — The  causes  of  aphthous  stomatitis  are  usually  those  which 
produce  catarrhal  stomatitis,  viz:  gastro-intestinal  disorders,  extension 
of  inflammatory  conditions  of  the  respiratory  tract  to  the  mucous  mem- 
brane of  the  mouth,  unwholesome  food,  uncleanness  of  the  feeding 
apparatus,  and  the  nervous  irritation  induced  by  the  eruption  of  the 
deciduous  teeth;  to  which  may  be  added  mechanical  irritation  from  the 
roughened  surfaces  and  sharp  edges  of  carious  teeth,  and  the  irritating 
effect  of  certain  chemical  substances  which  have  been  taken  into  the 
mouth.  The  acids  of  certain  fruits,  strawberries  and  tomatoes  particu- 
larly, are  not  infrequently  the  cause  of  aphthous  patches. 

Symptoms. — The  local  symptoms  are  the  presence  upon  the  lin- 
gual, buccal,  and  labial  mucous  membrane  of  numerous  small  white  or 
yellowish-white  patches,  slightly  elevated  above  the  surrounding  mem- 
brane, and  which  are  exceedingly  sensitive  to  the  touch,  to  hot  or 
highly  seasoned  food,  and  to  acids.  The  most  prominent  symptoms 
are  the  pain  and  the  soreness  of  the  mouth  which  prevents  the  child 
from  taking  food.  The  eruption  passes  away  under  appropriate  treat- 
ment, but  it  is  prone  to  frequent  recurrence,  especially  in  debilitated 
children  and  adults  who  are  suffering  from  indigestion  and  other  de- 
rangements of  the  digestive  functions. 

The  constitutional  symptoms  rarely  exceed  a  slight  feverishness, 
loss  of  appetite,  thirst,  and  irritability  (Day).  When  the  temperature 
rises  more  than  one  or  two  degrees  above  the  normal,  this  is  good  evi- 
dence that  the  child  is  suffering  from  a  more  serious  disorder  of  which 
the  oral  affection  may  be  only  a  symptomatic  expression. 

Treatment. — There  is  no  special  treatment  for  this  affection  other 
than  that  already  indicated  in  the  treatment  of  catarrhal  stomatitis,  ex- 
cept that  the  inflamed  parts  of  the  mucous  membrane  may  be  lightly 
brushed  over  with  a  camel's-hair  pencil  which  has  been  dipped  in  a 


STOMATITIS. 


287 


solution  of  boric  acid  in  glycerol.  In  the  more  obstinate  cases  the 
patches  may  be  touched  with  a  solution  of  silver  nitrate  (gr.  v  to  fi.5j 
of  water). 

Stomatitis  Parasitica. — This  disease  is  popularly  known  as  thrush 
or  white  mouth,  and  is  a  parasitic  or  mycotic  afifection,  generally  found 
in  the  mouths  of  infants  and  little  children.  The  parasite  is  a  confer- 
void  plant  or  fungus  (Fig.  119),  the  thrush  fungus  or  o'idium  albicans, 
which  grows  upon  and  between  the  layers  of  the  epithelium,  but  de- 
velops most  rapidly  upon  the  squamous  type  of  this  tissue.  The  dis- 
ease is  most  commonly  seen  in  the  mouths  of  artificially-fed  children, 
and  is  due  to  imperfect  cleansing  of  the  feeding  apparatus.     Being  of 

Fig.   no. 


OiDiuM  Albicans  (Thrush  Fukgus)  in  Kidney  of  Mouse  after  Subcutaneous  Inoculation. 

X  1000. 

mycotic  origin,  it  is  readily  conveyed  from  the  mouth  of  one  child  to 
another.  It  is  most  frequently  seen  in  foundling  and  maternity  hos- 
pitals. To  prevent  its  spreading  constant  care  should  be  exercised  in 
the  examination  of  the  children's  mouths,  and  under  no  circumstances 
should  the  promiscuous  use  of  nursing  bottles  be  allowed.  When  the 
disease  occurs  in  adult  life  it  is  always  associated  with  a  debilitated 
condition  of  the  system,  and  is  considered  as  an  unfavorable  omen. 
The  growth  of  the  organism  is  favored  by  an  abnormal  acidity  of  the 
oral  secretions,  a  debilitated  condition  of  the  system,  and  bad  sanitary 
and  hygienic  surroundings. 

Symptoms. — ^The  disease  is  characterized  by  a  dry,  feverish  mouth, 
and  scanty  salivary  secretion.     Small,  white,  elevated  patches  are  found 


288  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

upon  the  inside  of  the  hps,  cheeks,  angles  of  the  mouth,  and  sides  of  the 
tongue  (Day). 

These  elevated  patches,  after  two  or  three  days,  assume  a  curdy  or 
soft  cheesy  appearance.  This  "thrush  film"  can  be  removed  as  a  false 
membrane,  leaving  a  denuded  surface  which  bleeds  easily,  until  it  is 
again  covered  by  another  parasitic  growth.  The  denuded  or  excori- 
ated surfaces  are  exceedingly  sensitive,  and  render  nursing  and  swal- 
lowing very  painful.  These  patches  sometimes  extend  to  the  pharynx, 
tonsils,  and  hard  palate,  and  may  even  develop  in  the  oesophagus  and 
air-passages. 

The  constitutional  symptoms  are  disorders  of  the  stomach  and  in- 
testines, with  vomiting  and  diarrhea.  The  excreta  from  the  bowels 
are  greenish  in  color,  mixed  with  curdy  masses  of  milk,  and  are  often 
acrid,  causing  excoriation  of  the  anus,  buttock,  perineum,  and  in  the 
male  sex  of  the  scrotum.  Elevation  of  temperature  and  acceleration 
of  the  pulse  are  not  uncommon  symptoms.  The  disease  sometimes 
terminates  fatally  in  debilitated  children  from  exhaustion  and  inanition. 

Treatment. — The  treatment  consists  of  clearing  the  alimentary  tract 
with  a  dose  of  castor  oil  or  calomel,  and  a  proper  regulation  of  the  diet. 
Day  recommends  the  use  of  chlorate  of  potash  administered  in  small 
dose  of  a  few  grains,  three  times  per  diem,  as  he  considers  it  a  specific. 

The  local  treatment  consists  of  washing  the  mouth  after  each  meal 
with  some  bland  antiseptic  solution,  and  the  application  of  boric  acid 
in  glycerol  or  honey.  In  the  more  severe  cases  the  patches  may  be 
lightly  touched  with  a  solution  of  silver  nitrate,  gr.  v  to  water  fl^j. 
Occasionally  it  may  be  necessary  when  there  is  a  tendency  to  ulcera- 
tion at  the  bottom  of  the  patches  to  touch  them  with  the  stick  nitrate. 
Sir  Wilham  Jenner  recommended  a  solution  of  soda  sulfite  3J  to  flgj 
of  water. 

Stomatitis  Ulcerosa. — Ulcerative  stomatitis  (cancrum  oris)  is  a 
much  more  serious  afifection  than  any  of  the  forms  previously  described, 
although  it  is  not  considered  to  be  a  dangerous  malady,  like  the  other 
forms  of  the  affection.  It  is  in  general  a  disease  of  childhood,  and 
is  most  frequently  observed  between  the  fifth  and  tenth  years.  The 
disease  is  rarely  seen  outside  of  hospital  wards  and  public  clinics,  as  it 
seldom  attacks  the  children  of  the  better  class  of  society.  Individuals 
who  are  "badly  nourished  or  debilitated  from  disease,  such  as  scrofu- 
lous disorders,  intestinal  complaints  accompanied  by  exhausting  dis- 
charges, typhoid  fever,  diabetes  or  scurvy"  (Ziegler),  the  exanthems, 
pneumonia,  or  irritation  from  diseased  teeth,  are  most  susceptible  to 
the  affection.  Convalescence  from  exhausting  acute  disease  predis- 
poses to  an  attack.  There  seems  to  be  good  evidence  that  the  disease  is 
sometimes  epidemic,  as  several  cases  are  usually  seen  at  about  the  same 
period,  while  on  the  other  hand,  long  periods  may  elapse  without  the 


STOMATITIS.  289 

appearance  of  a  single  case  (Swift).  Unsanitary  surroundings,  like 
cold,  damp,  impure  air,  seem  to  favor  its  appearance  and  its  dissemi- 
nation. 

The  disease  is  generally  acute  in  type,  rarely  chronic,  and  "always 
starts  from  the  alveolar  margin  of  the  gums"  (Bohn). 

Causes. — The  causes  are,  principally,  bad  hygienic  surroundings, 
unwholesome  food,  insufficient  nourishment,  debility  from  acute  and 
exhausting  diseases.  Local  injuries  and  irritations  from  diseased 
teeth,  and  the  chronic  poisoning  by  mercury,  phosphorus,  lead,  and 
copper  (Ziegler)  may  also  be  causative  factors  in  the  production  of  the 
disease. 

Symptoms. — The  disease  begins  in  the  margins  of  the  gums  by 
redness,  swelling,  pain  or  sense  of  discomfort,  tenderness  and  loosening 
of  the  gums  from  around  the  teeth.  The  loosened  margins  and  festoons 
of  the  gums  become  swollen,  congested,  and  partially  cover  the  teeth, 
which  now  become  loosened,  and  hemorrhage  is  easily  provoked. 
Later  the  swollen  and  congested  gum  becomes  discolored,  softens,  and 
sloughs  away  as  a  yellowish  mass,  leaving  an  irregular,  ulcerating  sur- 
face. The  ulcers  thus  formed  present  an  angry  red  surface  and  thick- 
ened borders,  the  center  of  the  ulcer  being  sometimes  partially  covered 
with  shreds  of  necrotic  soft  tissue.  The  progress  of  the  ulceration  is 
rapid,  extending  to  the  deeper  tissues  and  to  the  surrounding  parts  of 
the  cheeks  and  the  lips.  It  occasionally  involves  the  periosteum  and 
the  bone,  causing  necrosis  and  exfoliation  of  considerable  portions  of 
the  alveolar  process  and  the  neighboring  teeth. 

In  the  milder  cases  involving  a  limited  area  of  ulceration,  there 
is  a  slight  rise  in  the  temperature,  accompanied  by  other  mild  febrile 
symptoms,  which  may  last  for  a  few  days  and  subside  upon  the  heal- 
ing of  the  ulcerations.  In  the  more  severe  cases  in  which  the  ulcera- 
tion is  extensive  and  involves  the  periosteum  and  the  bone,  the  tem- 
perature may  run  high  and  not  subside  for  several  days,  dependent 
upon  the  extent  of  the  ulceration  and  the  tissues  involved.  In  those 
cases  in  which  the  ulcerations  are  deep,  foul,  and  extensive  (Swift),  the 
breath  is  offensive,  and  the  saliva,  which  is  increased  in  quantity,  is  dis- 
colored with  pus  and  blood,  and  emits  a  foul  odor ;  the  salivary  glands 
become  enlarged  and  tender,  and  the  jaws  swollen  and  stiff.  Some- 
times the  disease  resembles  a  gangrenous  stomatitis,  and  there  is  al- 
ways danger  that  it  may  assume  such  form.  (See  Noma,  chapter  on 
Gangrene.)  The  prognosis  of  ulcerative  stomatitis  is  good  even  in  the 
severe  form,  provided  it  does  not  become  gangrenous. 

Treatment. — ^This  consists  in  the  first  place  of  correcting  the  bad 
condition  of  the  health  which  may  have  been  the  cause  of  the  affection. 
The  regulation  of  the  diet  to  the  individual  needs  of  the  patient  is  a 
matter  of  prime  importance,  and  should  receive  immediate  attention. 


290  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

If  the  surroundings  are  unhealthy  the  child  should  be  removed  as 
quickly  as  possible  to  a  more  healthful  environment,  preferably  to  the 
country  or  the  seashore.  Stimulants  and  tonics  may  also  be  neces- 
sary to  assist  the  enfeebled  system  to  regain  its  normal  tone,  but 
change  of  air  and  good  food  are  the  most  valuable  means  at  our  dis- 
posal in  the  cure  of  this  affection.  In  the  local  treatment  the  applica- 
tion of  a  solution  of  the  chlorate  of  potassium  every  two  or  three  hours 
is  a  valuable  remedy.  Swift  recommends  a  solution  of  the  sulfate  of 
copper  gr.  v  to  fl  § j  of  water,  or  boric  acid  in  glycerol  or  honey.  Day 
advocates  the  use  of  the  silver  nitrate  solution  gr.  v  to  floj  of  water, 
used  in  conjunction  with  the  chlorate  of  potassium  solution;  also  the 
painting  of  the  ulcers  with  the  tincture  of  iron  and  glycerol. 

Stomatitis  Ulcerosa  Nocens. — This  is  an  infectious  ulcerative 
stomatitis  which  sometimes  follows  injuries  to  the  gums  from  the  ex- 
traction of  teeth,  abrasions  from  hard  foods,  too  vigorous  use  of  the 
tooth-brush  and  other  traumatisms. 

The  clinical  characteristics  of  this  form  of  the  disease  are  the  for- 
mation of  ulcers  at  some  point  of  injury,  which  at  first  appear  in 
nowise  different  from  the  ordinary  form  of  a  localized  ulcerative  stoma- 
titis, but  which  after  the  lapse  of  twenty-four  to  forty-eight  hours  be- 
gins to  spread  rapidly  along  the  margins  of  the  gingivae  in  all  direc- 
tions, involving  both  jaws  and  sometimes  extending  to  the  hard  palate 
and  the  floor  of  the  mouth.  The  margins  of  the  gums  assume  a  general 
ulcerative  condition,  accompanied  by  swelling,  redness,  and  consider- 
able congestion  of  the  parts,  which  bleed  easily.  Later  they  become 
covered  with  a  dirty  white  or  yellowish-white  pellicle  or  membrane, — 
somewhat  resembling  the  thrush  film — which  sloughs  off  after  a  day  or 
two,  destroying  the  festoons  and  leaving  a  ragged  surface.  The 
denuded  surface  is  very  red,  and  covered  with  coarse  granulations 
which  bleed  upon  the  slightest  provocation.  The  gums  are  loosened 
from  the  necks  of  the  teeth,  and  the  borders  of  the  alveolar  processes 
are  exposed.  Pus  mixed  with  blood  exudes  from  the  inflamed  tissue 
about  the  necks  of  the  teeth.  The  breath  and  excretions  are  very  fetid, 
and  salivation  is  profuse.  In  these  respects  the  symptoms  resemble 
mercurial  ptyalism.  The  ulcerated  surfaces  are  exceedingly  sensitive, 
and  motions  of  the  tongue  and  lips  on  this  account  are  quite  painful. 
Food  is  taken  with  difficulty. 

Accompanying  the  local  manifestations,  there  is  a  general  febrile 
condition,  temperature  rangmg  from  100'^  to  101°  F.,  thirst,  loss  of 
appetite  and  general  malaise,  sleeplessness,  and  irritability  of  temper. 

In  illustration  of  the  above  clinical  features  of  the  disease,  the  fol- 
lowing cases  are  introduced. 

Case  I. — Mr.  A.,  American,  aged  twenty-four  years,  clerk,  was 
referred  to  a  dental  specialist  for  treatment. 


STOMATITIS.  291 

History:  This  gentleman  had  an  abscessed  lower  molar  of  the 
right  side  extracted,  which  had  caused  considerable  swelling  of  the  jaw. 
The  gum  tissue  had  been  somewhat  lacerated  upon  the  lingual  side  in 
the  effort  to  remove  the  offending  root.  Two  days  later  he  returned 
with  the  injured  gum  ulcerated,  the  ulceration  spreading  to  the  adjoin- 
ing teeth.  The  festoons  of  the  gums  were  detached  from  the  alveolar 
process  and  the  bone  denuded.  Antiseptics  had  been  used  to  cleanse 
the  mouth,  the  alveolus  irrigated  and  dressed,  and  a  listerine  mouth- 
wash prescribed.  The  disease,  however,  spread  so  rapidly  that  in  forty- 
eight  hours  the  gums  of  the  entire  lower  jaw  were  involved,  and  it  had 
attacked  the  anterior  portion  of  the  upper  jaw.  This  was  the  condition 
when  the  case  first  came  under  the  notice  of  the  writer. 

Diligent  inquiry  could  not  discover  any  constitutional  conditions, 
like  syphilis,  mercurial  or  lead  poisoning,  etc.,  which  would  account  for 
the  presence  of  the  disease.  He  had,  however,  recently  been  ill  for  a 
couple  of  weeks  from  a  mild  attack  of  la  grippe. 

Treatment:  The  treatment  consisted  of  first  cleansing  the  mouth  by 
irrigating  it  with  a  saturated  solution  of  boric  acid,  followed  by  a  50 
per  cent,  solution  of  12-volume  hydrogen  peroxid  in  water,  sprayed  into 
the  mouth  and  the  approximal  spaces  between  the  teeth.  The  mouth 
was  again  irrigated  with  the  boric  acid  solution  to  remove  all  debris 
and  the  foam  caused  by  the  use  of  the  peroxid ;  after  which  the  gums 
were  carefully  dried  and  protected  with  rolls  of  bibulous  paper,  and  the 
ulcerated  surfaces  swabbed  with  a  10  per  cent,  solution  of  zinc  chlorid. 

The  patient  was  furnished  with  a  bulb  atomizer,  and  instructed  to 
spray  the  mouth  every  two  hours  with  25  per  cent,  listerine  solution. 

This  line  of  treatment  was  followed  every  day  for  a  week,  except 
the  application  of  the  zinc  chlorid,  which  did  not  seem  necessary  after 
the  third  day,  as  marked  improvement  took  place  from  this  date.  The 
case  was  discharged  cured  at  the  end  of  ten  days. 

The  only  constitutional  treatment  was  a  saline  cathartic,  which 
seemed  to  be  indicated  to  relieve  a  tendency  to  constipation.  The  fact 
that  local  treatment  alone,  except  that  just  indicated,  was  sufficient  to 
control  the  case,  precludes  the  possibility  of  syphilitic  infection  being 
the  cause  of  the  affection. 

Case  II. — This  patient  was  a  married  man,  aged  thirty-four  years, 
and  of  English  birth,,  formerly  a  practicing  dentist,  but  now  an  expert 
accountant. 

History:  Patient  states  that  he  has  been  overworked  of  late,  and 
not  well,  that  his  gums  had  been  congested  and  bled  when  the  teeth 
were  brushed;  and  thinking  that  perhaps  he  had  not  been  vigorous 
enough  in  the  use  of  the  tooth-brush,  he  bought  a  new  one  which  was 
quite  hard  and  gave  them  a  most  thorough  brushing  before  retiring. 
Next  morning  his  mouth  was  so  greatly  inflamed  that  he  could  not  use 


292  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

the  tooth-brush  or  masticate  his  food,  or  even  take  a  cup  of  hot  coffee. 
For  the  next  two  days  he  tried  to  allay  the  inflammation  with  various 
soothing  preparations,  with  no  benefit.  At  this  stage  of  the  case  he 
presented  for  examination  and  treatment. 

Examination  of  the  mouth  revealed  extensive  ulceration  of  the 
margins  of  the  gums  of  both  jaws,  with  ulcerating  streaks  upon  the 
roof  of  the  mouth,  extending  from  the  region  of  the  first  molars  on  each 
side  nearly  to  the  median  line,  and  looking  as  though  they  had  been 
cauterized  with  silver  nitrate.  The  ulcerations  in  all  parts  of  the  mouth 
were  covered  with  the  same  dirty-white  or  yellowish-white  film.  The 
gums  were  separated  from  the  borders  of  the  alveolar  process,  leaving 
the  bone  exposed.  All  of  the  other  symptoms  correspond  to  those  of 
Case  I. 

In  Case  II,  however,  nearly  every  tooth  in  the  mouth  had  a  ring  of 
salivary  calculus  encircling  the  cervix.  This  was  no  doubt  the  cause  of 
the  congestion  of  the  gums  which  induced  the  bleeding  on  brushing. 

Treatment  consisted  of  first  cleansing  the  mouth,  and  then  remov- 
ing the  salivary  calculus.  In  all  other  respects  the  treatment  was  the 
same  as  in  Case  I.  He  made  a  rapid  recovery  and  was  discharged  at 
the  end  of  two  weeks. 

Case  III.— Was  almost  identical  with  Case  I.  It  originated  from 
the  same  cause,  viz,  the  extraction  of  an  abscessed  lower  molar,  fol- 
lowed by  ulceration  of  the  gingival  wound  and  extension  of  the  ulcera- 
tive process  to  the  gingival  borders  of  both  jaws.  In  this  case,  which 
occurred  in  a  young  Jew,  twenty-four  years  of  age,  there  was  a  clear 
history  of  syphilis,  infection  having  taken  place  two  years  before.  He 
had  visited  Hot  Springs  and  taken  a  course  of  treatment,  but  had 
taken  no  mercury  or  iodids  since  his  return,  four  months  before. 

The  treatment  prescribed  in  the  other  cases  was  followed  in  this, 
with  the  exception  that  after  the  third  day  of  treatment,  in  consultation 
with  his  family  physician,  he  was  placed  upon  the  usual  course  of  treat- 
ment with  the  iodids.  He  rapidly  improved  under  the  local  treatment 
from  the  first,  and  at  the  end  of  ten  days  all  of  the  local  symptoms  had 
disappeared.  From  this  we  think  the  inference  may  be  safely  drawn 
that  the  local  disease  was  not  the  result  of  his  syphilitic  condition,  as  it 
is  hardly  to  be  supposed  that  the  constitutional  effect  of  the  iodids 
would  be  manifested  in  so  short  a  period.  It  was  evident,  also,  that  the 
case  was  improving  before  the  iodids  were  administered. 

Neither  can  the  first  or  third  cases  be  fairly  attributed  to  infection 
from  unclean  instruments,  as  I  am  sure  that  the  greatest  care  was 
observed  in  both  cases  to  prevent  such  a  contingency.  The  explanation 
would  rather,  it  seems  to  me,  be  that  of  auto-infection  from  the  pus 
micro-organisms  of  the  alveolar  abscess  coming  in  contact  with  a 
freshly  wounded  surface  of  the  gum,  or  from  some  of  the  other  patho- 


STOMATITIS,  293 

genie  organisms  which  so  constantly  inhabit  the  mouths  of  even  cleanly 
persons. 

The  second  case  was  also,  without  doubt,  due  to  auto-infection 
from  the  last-named  causes,  through  the  brushing  and  lacerating  of  the 
already  inflamed  gums ;  thus  furnishing  the  only  condition  lacking  be- 
fore to  establish  an  infectious  inflammation,  which  by  reason  of  the 
debilitated  condition  of  the  system  it  was  unable  to  successfully  resist. 

The  acute  character  of  the  symptoms  and  the  rapid  spreading  of 
the  ulceration  from  the  initial  point  of  injury  seem  to  prove  the  infec- 
tious nature  of  the  disease. 


CHAPTER    XXXI. 
LEUCOPLAKIA. 

Definition. — Leucoplakia  (from  the  Greek  Xewo?, white,  and  TrXa^, a 
surface)  literally  "white  surface"  or  "whitening  of  the  surface." 

Leucoplakia  is  a  chronic  superficial  inflammation  affecting  the  mu- 
cous membrane  of  the  tongue,  the  palate,  the  cheeks,  and  the  gums,  and 
is  characterized  by  the  presence  of  pearly-white  or  bluish-white  plaques 
or  patches ;  in  some  cases  small,  in  others  covering  the  entire  dorsum 
of  the  tongue,  the  cheeks  from  the  angle  of  the  mouth  back  to  the 
fauces,  the  palate,  or  the  entire  buccal  surface  of  the  gums.  Various 
terms,  such  as  "leucoplakia  linguae,"  "leucoplakia  buccalis,"  and  "leuco- 
plakia gingivae,"  have  been  introduced  to  designate  the  location  of  the 
disease. 

Nomenclature. — The  disease  is  variously  known  as  psoriasis 
linguae,  zona  (herpes  zoster),  smoker's  patch,  leucoma,  leucoplakia, 
ichthyosis,  leucokeratosis,  leucoplasia,  leucoplaques,  plaques  opalines^ 
and  superficial  glossitis. 

Varieties. — There  are  two  forms  of  leucoplaques  found  in  the 
human  mouth;  the  milky  opaline  patches  (plaques  opalines),  rep- 
resented by  the  mucous  patches  of  condylomata  of  secondary  syphilis, 
and  the  non-syphilitic,  smooth  white  or  pearly-white  patches  for  which 
Schwimmer  was  the  first  to  propose  the  term  "leucoplakia,"  and 
Hutchinson  "leucoma."  The  French  writers  generally  refer  to  the  dis- 
ease as  "psoriasis  linguae,"  or  plaques  opalines.  Hulke  has  described 
a  warty  variety  of  the  disease,  and  applied  to  it  the  term  "ichthyosis 
linguae." 

The  plaques  opalines,  or  the  mucous  patches  of  secondary  syphilis, 
are  grayish-white  and  curdy  in  appearance,  resembling  the  superficial 
corrosion  caused  by  the  application  of  the  nitrate  of  silver  to  the 
mucous  membrane;  while  the  plaques  of  leucoplakia  are  usually  thin, 
shiny,  bluish-white,  white  or  pearly  in  color,  sometimes  having  a 
yellowish  tinge,  but  this,  according  to  Butlin,  is  almost  always  due  to 
the  stain  of  tobacco  or  some  other  extraneous  substance.  These  two 
varieties  of  leucoplaques  may  be  further  differentiated  by  the  slight 
elevation  of  the  syphilitic  mucous  patches,  the  secretion  of  a  thin 
watery  fluid,  which  is  the  potent  source  of  contagion,  and  their  ten- 

294 


LEUCOPLAKIA.  295 

dency  to  become  painful  and  to  ulceration;  while  in  leucoplakia  the 
patches  are  not  elevated  above  the  surrounding  tissue,  except  in  the 
warty  form  (ichthyosis)  ;  they  are  not  painful  except  in  the  advanced 
stage  of  the  disease,  no  secretion  is  present,  and  ulceration  is  not  devel- 
oped until  the  disease  has  taken  on  a  malignant  form. 

To  the  latter  variety  of  leucoplaques — the  true  leucoma  or  leuco- 
plakia— the  writer  desires  to  call  especial  attention,  for  the  following 
reasons:  i.  It  is  an  exceedingly  dangerous  afifection,  often  being  a 
forerunner  of  carcinoma.  2.  It  is  a  disease  which,  from  its  innocent 
appearance  and  the  painless  character  of  its  early  stages,  is  seldom 
recognized  until  the  disease  has  progressed  to  a  stage  which  renders 
a  favorable  prognosis  exceedingly  doubtful.  3.  The  disease  seems, 
from  personal  observation,  to  be  on  the  increase.  4.  The  dental  sur- 
geon, from  the  very  nature  of  his  specialty,  is  in  a  position  to  see  and 
recognize  the  disease  in  its  earliest  stages,  and  to  warn  the  patient  of  his 
condition  before  it  has  progressed  so  far  as  to  prove  a  menace  to  life. 

The  disease  in  its  earlier  stages  is  much  more  likely  to  come  under 
the  notice  of  the  observing  dentist,  or  stomatologist,  than  of  the  sur- 
geon or  the  laryngologist.  As  a  rule,  the  patient  does  not  consult  a 
surgeon  until  the  disease  becomes  troublesome ;  it  may  then  have  pro- 
gressed so  far  as  to  give  unmistakable  evidences  of  degenerative 
changes  of  a  malignant  character.  The  dentist,  therefore,  should  be  so 
familiar  w^ith  the  characteristic  features  of  the  disease  that  he  could 
recognize  it  at  a  glance ;  while  it  would  be  his  duty  to  impress  upon 
the  patient  the  urgent  necessity  of  consulting  an  oral  specialist  with 
the  view  of  instituting  measures  calculated  to  arrest  its  further  devel- 
opment, or  for  its  complete  extirpation. 

Etiology. — The  etiology  of  leucoplakia  is  by  no  means  a  settled 
question  in  oral  pathology.  Marked  differences  of  opinion  still  exist 
among  the  very  best  pathologists  as  to  the  causative  factors  in  the  pro- 
duction of  the  affection.  The  earlier  writers  looked  upon  the  disease 
as  a  local  manifestation  of  psoriasis ;  others  considered  it  due  to  certain 
other  forms  of  skin  disease,  like  zona  (herpes  zoster  or  hives)  and 
lichen  planus ;  many  have  looked  upon  the  disease  as  a  circumscribed 
chronic  inflammation  of  the  oral  mucous  membrane,  due  to  syphilis, 
and  still  others  have  thought  it  a  distinct  affection  produced  by  the 
local  irritation  induced  by  smoking  or  chewing  tobacco.  The  inflam- 
matory conditions  of  the  oral  mucous  membrane  and  of  the  tongue 
resemble  in  certain  respects  the  inflammatory  conditions  of  the  skin, 
while  in  others  they  present  the  characteristic  features  of  mucous 
membrane  in  general.     (Ziegler.) 

Various  inflammations  and  eruptive  diseases  of  the  skin  have  their 
counterpart  in  the  mucous  membranes,  as  for  instance  in  erysipelas, 
which  is  an  infectious  inflammation  usually  manifested  in  the  skin,  but 


296  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

which  often  extends  to  the  mucous  membrane,  especially  of  the  mouth 
and  nose,  while  upon  the  other  hand  it  may  originate  in  some  wound 
or  inflammation  of  the  mucous  membrane,  and  later  extend  to  and 
involve  the  skin,  as  occurred  in  a  case  recently  seen  in  consultation, 
in  which  the  disease  developed  as  a  complication  of  acute  septicemia 
caused  by  an  alveolar  abscess,  and  which  terminated  fatally.  Zona  is 
another  example  in  the  same  line.  Although  zona  is  an  eruptive  dis- 
ease of  the  skin,  it  often  attacks  the  mucous  membrane  of  the  lips  and 
of  the  genital  organs  at  the  junction  of  the  skin  with  the  mucous  mem- 
brane. Lichen  planus,  another  skin  affection,  sometimes  produces 
buccal  lesions.  These  lesions  have  been  described  by  Wilson,  Hutchin- 
son, Kaposi,  and  Crocker  as  whitish,  thickened  and  uniformly  elevated 
plaques  upon  the  mucous  surface,  sometimes  grayish  white  or  resem- 
bHng  in  color  the  places  which  have  been  cauterized  with  nitrate  of 
silver.  It  is  not  strange,  therefore,  that  the  earlier  writers  should  look 
upon  leucoplakia  as  a  manifestation  of  some  of  these  forms  of  skin 
diseases,  aind  particularly  of  psoriasis,  which  it  somewhat  closely 
simulates  in  its  earlier  stages. 

Most  modern  writers  look  upon  leucoplakia  as  an  entirely  distinct 
affection,  having  no  association  with  psoriasis  in  any  of  its  forms. 
Hyde  says:  "Psoriasis  is  not  known  to  affect  the  mucous  surfaces. 
The  lesions  of  so-called  psoriasis  linguae  are  those  of  leucoplakia  buc- 
calis,  of  smoker's  patches,  of  syphilitic  disease  of  the  mouth,  or  of  flat 
epithelioma."  Nicholson,  however,  still  holds  to  the  old  theory  that 
leucoplakia  is  a  local  manifestation  of  a  skin  affection,  and  maintains 
that  the  disease  is  zona  (herpes  zoster)  located  in  the  mucous  mem- 
brane. The  peculiar  burning  sensation  that  accompanies  the  white 
patches  located  upon  the  lingual  mucous  membrane  he  considers  as 
almost  a  pathognomonic  sign,  and  calls  attention  to  the  fact  that  one 
or  two  herpetic  vesicles  may  appear  on  the  lower  surface  of  the  tongue 
during  the  course  of  the  disease.  Park  is  of  the  opinion  that  leu- 
coplakia is  often  due  to  syphilis,  and  says :  "These  late  and  recurring 
lesions  (syphilitic  mucous  patches)  lose  their  moist  character,  become 
quite  smooth,  shiny,  of  a  bluish-white  color,  and  may  mark  the  be- 
ginning of  the  condition  known  as  leucokeratosis."  Butlin,  than 
whom  there  is  no  greater  authority  upon  such  matters  (Butlin's  "Dis- 
eases of  the  Tongue"),  considers  smoker's  patches,  leucoplakia  and 
ichthyosis  as  simply  different  manifestations  of  the  same  disease, 
namely,  chronic  superficial  glossitis,  which  may  have  its  origin  in  sev- 
eral forms  of  irritation,  both  chemic  and  mechanic,  and  which  may  act 
singly  or  combined. 

Predisposing  causes. — Butlin  agrees  with  Debove  in  the  state- 
ment that  there  is  in  most  patients  some  condition  which  predisposes 
to  the  disease.    He  says :   "I  suspect  that  the  mucous  membrane  of  the 


LEUCOPLAKIA.  297 

tongue  in  leucomatous  subjects  is  from  the  first  less  thick  and  stable, 
and  more  easily  irritated  than  in  the  majority  of  persons.  As  some 
persons  are  known  to  have  irritable  and  delicate  skins,  easily  inflamed 
and  prone  to  eruptions,  and  as  some  of  those  persons  develop  affections 
of  the  skin  which  are  very  chronic  and  difficult  to  heal,  so  I  believe  other 
people  have  tongues  whose  mucous  membrane  is  abnormally  delicate, 
prone  to  chronic  inflammation,  and  difficult  to  cure  when  the  disease 
has  been  excited."  It  has  been  suggested  that  chronic  dyspepsia  and 
the  rheumatic  and  gouty  diathesis  might  be  a  predisposing  cause  of  the 
disease,  but  the  evidence  upon  this  point  does  not  seem  to  be  sufficiently 
strong  to  give  any  real  weight  to  its  consideration.  Sajous  says  he  has 
reason  to  think  that  gout  is  a  cause  of  leucoplakia,  for  he  has  seen  it  in 
gouty  women  who  did  not  smoke  and  were  not  syphilitic. 

Age  and  sex  are  both  very  important  predisposing  causes  of  the 
disease.  Leucoplakia  is  rarely  seen  in  persons  under  twenty  years  of 
age,  even  in  boys  addicted  to  smoking;  while,  on  the  other  hand,  it  is 
rarely  seen  to  commence  in  persons  over  sixty  years  of  age.  Women 
seem  to  be  almost  entirely  exempt  from  the  disease.  Of  the  twelve 
cases  seen  by  the  writer  all  but  one  were  in  men,  and  occurred  between 
the  ages  of  forty  and  seventy-four  years.  Du  Castel  has  reported  a 
■case  in  which  the  disease  had  existed  since  the  age  of  twelve  years  in  a 
man  who  had  never  used  tobacco.  In  one  of  the  writer's  cases,  an 
elderly  female,  the  disease  had  existed  since  she  was  sixteen  years  of 
age.  She  had  been  addicted  to  smoking  from  fourteen  or  fifteen  years 
of  age. 

Exciting  causes. — Among  the  most  common  exciting  causes  of  leu- 
coplakia may  be  mentioned  the  irritation  produced  by  the  habitual  use 
of  tobacco,  particularly  smoking;  the  later  recurring  lesions  of  the 
mucous  membrane  due  to  the  secondary  manifestations  of  syphilis — the 
mucous  plaques,  acting  locally  upon  the  tongue  or  the  buccal  mucous 
membrane ;  the  frequent  use  of  undiluted  spirituous  liquors ;  the  drink- 
ing of  very  hot  fluids,  or  eating  of  very  hot  or  highly  spiced  foods ;  the 
mechanic  irritation  of  teeth  roughened  by  the  process  of  caries,  frac- 
tures, or  the  accumulation  of  salivary  calculus;  the  irritation  from 
dental  plates  which  are  rough,  ill-fitting,  or  made  of  material  which  is 
irritating  to  the  delicate  mucous  membrane  of  the  mouth.  Wallenberg 
is  of  the  opinion  that  the  use  of  tobacco  is  the  most  frequent  source  of 
leucoplakia,  and  believes  the  disease  is  produced  by  the  irritation  of  the 
volatile  and  empyreumatic  oils  liberated  in  smoking  it.  The  writer 
has  no  hesitation  in  expressing  it  as  his  opinion  that  the  use  of  the 
pipe  is  on  this  account  much  more  dangerous  to  a  sensitive  mouth  than 
the  smoking  of  cigars  or  cigarettes,  as  the  pipe,  from  long  use,  is  gen- 
erally saturated  with  these  oils,  which  often  come  into  direct  contact 
with  the  mucous  membrane  of  the  tongue,  causing  smarting  and  bum- 


298  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

ing  sensations,  with  more  or  less  irritation.  In  the  habitual  smoker 
the  irritation  becomes  chronic,  producing  a  thickening  of  the  epidermal 
layer  and  infiltration  of  the  papillary  layer  with  round  cells. 

Erb  collected  and  analyzed  240  cases  of  leucoplakia,  and  states  as 
his  belief  that  the  lesions  are,  as  a  rule,  due  to  "epithelial  thickenings 
resulting  from  syphilitic  mucous  patches."  Of  this  number  two  only 
were  women,  and  these  were  both  syphilitic.  In  about  60  per  cent,  of 
the  cases  there  was  a  clear  history  of  syphilis,  while  in  many  others  a 
very  strong  suspicion  of  such  an  infection  existed.  In  four  or  five  cases 
antisyphilitic  treatment  either  cured  or  greatly  improved  the  condi- 
tions, even  when  they  had  existed  for  a  long  time.  Out  of  148  cases 
who  were  interrogated  as  to  their  use  of  tobacco,  45  smoked  little,  or 
not  at  all;  loi  smoked  moderately,  and  2  excessively.  Syphilis  alone 
occurred  in  36  of  these  cases,  smoking  alone  in  37,  syphilis  and  smok- 
ing occurred  in  64,  and  neither  in  1 1  cases.  The  following  conclusions 
were  reached:  i,  syphilis  or  smoking  alone  may  be  the  cause  of  this 
affection  in  about  the  same  proportion  of  cases ;  2,  in  a  majority  of 
cases  it  may  be  due  to  both ;  3,  it  rarely  appears  without  being  referable 
to  one  or  the  other  of  these  causes ;  4,  other  forms  of  irritation  seem 
to  play  only  a  minor  part.  He  believes  that  a  certain  predisposition 
must  be  assumed,  in  view  of  the  great  number  of  syphilitics  and  smok- 
ers who  never  develop  the  disease.     (Sajous'  Annual.) 

Symptoms  and  Diagnosis. — Leucoplakia  may  be  recognized  by  the 
presence  of  circumscribed  or  diffuse,  smooth,  white,  bluish-white  or 
pearly-white  radiating  patches  appearing  in  varying  numbers  upon 
the  mucous  membrane  of  the  cheeks,  lips,  gums,  palate,  or  tongue,. 
These  patches  often  coalesce  to  form  larger  ones.  In  their  earliest  stage 
they  are  not  elevated  above  the  surrounding  membrane,  are  smooth 
and  glistening  in  appearance,  and  range  in  size  from  tiny,  irregularly- 
outlined  spots,  to  large  plaques  the  size  of  a  silver  half-dollar,  or  even 
larger.  At  first  they  are  not  sensitive,  and  on  this  account  may  exist 
for  a  long  time  without  the  knowledge  of  the  patient.  Many  cases 
never  progress  beyond  this  stage.  Others  may  slowly  increase  in  size, 
thickness  and  intensity  of  color,  the  plaque  being  slightly  raised,  the 
surface  hard — corniHed — and  roughened.  Accompanying  this  stage — 
especially  when  the  disease  is  located  upon  the  dorsum  of  the  tongue — 
the  patient  will  complain  of  a  persistent  dryness  of  the  parts  and  in- 
ability to  speak  or  use  the  tongue  with  comfort,  except  by  frequent 
moistening  of  the  mouth.  Later,  fissures  appear  in  the  tongue,  and 
there  is  developed  a  smarting,  burning  sensation,  as  though  the  parts 
had  been  scalded.  Alcoholic  liquors,  fermented  beverages,  acid  fruits^ 
highly  seasoned  or  very  hot  food  or  drinks,  and  chewing  and  smoking 
tobacco  increase  these  sensations  and  sometimes  render  the  partaking 
of  food  a  very  great  discomfort.     Associated  with  this  condition  there 


PLATE  I\-. 


Cask  1.     i.Euriii'L akia  of  tong^ 


AGED  40   YEARS. 


V 

^^•4. 


/ 


TONGUE.       MALE.   AGED  45    YEARS. 


LEUCOl'LAKIA.  299 

is  a  tendency  of  some  portion  of  the  plaque  to  peel  off  or  slough  out 
from  time  to  time,  leaving  a  reddened  or  raw  surface  which  is  exceed- 
ingly sensitive,  and  sometimes  quite  painful.  Ulceration  may  follow 
and  degenerative  changes  develop,  ending  in  the  formation  of  a  car- 
cinoma. When  the  disease  is  in  the  tongue,  warty  growths  sometimes 
appear  in  the  leucomatous  patches,  which  show  a  marked  tendency 
under  the  stimulation  of  an  irritant  to  take  on  a  rapid  form  of  carci- 
nomatous degeneration. 

Authorities  are  not  agreed,  however,  as  to  the  earliest  develop- 
ments of  the  leucomatous  patch.  Schwimmer  and  Barker  described 
the  earliest  stage  of  the  disease  as  appearing  in  the  form  of  dark-red 
spots  or  reddish  patches,  which  later  are  covered  with  the  white  or 
pearly-white  surface.  Butlin,  Debove,  Nedopil,  and  nearly  all  other 
writers  upon  the  subject,  describe  the  first  stage  as  appearing  in  the 
form  of  radiating,  non-sensitive  white  or  pearly-white  plaques,  and  the 
writer  desires  to  state  that  the  testimony  of  his  own  observation  cor- 
responds with  the  latter  conclusion.  Another  fact  should  also  be  borne 
in  mind  in  diagnosing  this  affection,  viz :  The  progress  of  the  disease 
is  in  many  instances  very  slow  and  may  have  the  appearance  of  having 
reached  the  limits  of  its  development,  while  occasionally  it  may  disap- 
pear with  advancing  age.  On  the  other  hand,  the  disease,  which  has 
seemed  for  many  years  to  remain  in  about  the  same  condition,  may 
suddenly  assume  a  most  rapid  and  malignant  type  of  degeneration. 
Shield  reported  a  case  of  leucoplakia  linguae  in  a  man  seventy-five  years 
old,  for  whom,  two  years  before,  one-half  of  the  tongue  had  been  re- 
moved for  undoubted  carcinoma,  who  gave  a  previous  history  of  the 
presence  of  the  disease — "bad  tongue" — for  more  than  twenty  years. 

The  following  cases,  arranged  without  reference  to  their  chrono- 
logical order,  are  introduced  to  illustrate  the  various  stages  of  the 
disease  as  found  upon  the  tongue,  gums  and  cheeks,  and  are  takeii 
from  the  records  of  the  private  practice  of  the  writer : 

Case  i. — History:  This  was  a  case  of  leucoplakia  linguae  covering  the 
entire  dorsum  of  the  tongue.  (Plate  IV,  Fig.  i.)  Patient  was  a  Hebrew 
merchant,  forty  years  of  age,  of  robust  health,  and  an  inveterate  smoker  of 
cigars,  his  daily  indulgence  being  from  ten  to  fifteen  strong  Havanas.  The 
disease  had  never  given  him  any  inconvenience,  and  he  had  not  known  of  its 
presence  until  the  writer  called  his  attention  to  it,  when  making  an  examina- 
tion of  his  mouth.  He  was  advised  to  stop  smoking,  but  refused  point-blank 
under  any  circumstances.  There  was  no  history  of  skin  diseases  or  of  syphilis. 
He  drank  wine  in  moderation. 

Case  2. — History:  This  was  a  similar  case  of  leucoplakia  linguae,  in  which, 
however,  the  stage  of  degeneration  of  the  papillary  layer  had  begun.  (Plate 
IV,  Fig.  2.)  The  patient  was  of  German  birth,  forty-five  years  old,  of  large 
physique  and  good  health,  and  also  an  inveterate  smoker,  both  of  cigars  and 
the  pipe,  and  was  addicted  to  the  use  of  liquors,  but  rarely  to  excess.  He  had 
been  cognizant  for  several  years  of  the  abnormal  color  of  his  tongue,  but  it 


300  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

had  given  him  no  inconvenience  until  two  years  previous  to  the  time  when  he 
appeared  for  consultation,  and  was  referred  to  the  writer  by  Dr.  Gustav  Fiit- 
terer,  of  Chicago.  The  patient  complained  of  an  abnormal  dryness  of  the 
tongue,  tenderness  of  the  denuded  point,  and  a  smarting,  burning  sensation,  as 
though  the  tongue  had  been  scalded.  This  was  increased  by  taking  salty  or 
peppery  foods,  acids,  wines  or  spirits.  There  was  no  history  of  psoriasis,  zona, 
or  other  skin  disease,  nor  of  syphilis.  He  was  warned  of  the  dangers  of  the 
disease  assuming  malignant  characteristics  under  constant  irritation,  and  was 
advised  to  leave  off  the  use  of  tobacco  and  all  irritating  or  stimulating  foods  or 
drinks.  This  he  cheerfully  consented  to  do,  and  has  faithfully  followed.  The 
treatment  consisted  of:  i,  removing  the  salivary  calculus  and  all  sharp 
edges  of  the  teeth  and  thoroughly  polishing  the  surfaces.  Carious  teeth  were 
treated  by  filling  with  gold,  to  remove  all  possibility  of  mechanic  irritation; 
and  2,  the  application  every  other  day  of  tinct.  of  aconite  and  tinct.  of  iodin, 
equal  parts,  to  the  denuded  surface  of  the  tongue.  The  applications  caused 
slight  smarting  at  first,  but  this  subsided  after  a  few  minutes.  After  the  first 
week  a  slight  improvement  in  all  the  symptoms  was  noticed.  Whether  this 
was  due  to  the  local  application  or  to  the  removal  of  all  causes  of  irritation, 
was  a  question  in  the  mind  of  the  writer.  The  treatment,  however,  was 
continued,  and  at  the  end  of  two  months  the  symptoms,  with  the  exception 
of  the  abnormal  dryness  of  the  tongue,  had  entirely  disappeared  and  the 
denuded  part  was  covered  with  healthy-appearing  papillae.  Associated  with 
the  disease  of  the  tongue  were  plaques  upon  both  cheeks  and  the  right  superior 
gums.  This  case  was  seen  two  years  afterward,  and  the  patient  reported 
having  maintained  his  abstemious  habits,  with  the  result  of  having  perfect 
comfort.      The  plaques,  however,  had  not  disappeared. 

Case  3. — History:  This  case  illustrates  the  disease  as  seen  upon  the  gums 
of  both  jaws  in  a  gentleman  of  Canadian  birth,  fifty  years  of  age,  and  in 
robust  health.  (Plate  V,  Fig.  i.)  This  patient  was  also  a  great  smoker  of  the 
pipe.  The  disease  extended  from  the  first  bicuspid  tooth  backward  to  the 
maxillary  tuberosity  in  the  upper  jaw,  and  from  the  second  bicuspid  tooth  to 
the  angle  in  the  lower  jaw.  In  this  case  the  disease  had  not  caused  the  least 
inconvenience,  and  the  patient  had  not  noticed  any  abnormal  condition  of  the 
gums.  There  was  no  history  of  syphilis  or  of  any  skin  disease,  but  he  had 
gouty  tendencies;  he  used  spirits  moderately,  generally_  Scotch  whisky.  He 
was  cautioned  against  the  use  of  tobacco  and  spirits  and  stimulating  or 
pungent  foods  or  drinks,  and  advised  to  report  frequently  for  examination, 
which  he  has  done.  This  case  has  been  under  close  observation  for  over  eight 
years,  and  there  has  been  a  slight  extension  of  the  plaques,  but  as  the  disease 
does  not  trouble  him.  he  will  not  give  up  his  way  of  living. 

Case  4. — History:  This  case  shows  the  disease  in  its  early  stage,  located 
upon  the  alveolar  ridge,  in  a  Hebrew  gentleman  seventy-four  years  of  age, 
who  was  in  otherwise  good  health.  (Plate  V,  Fig.  2.)  He  was  not  cognizant 
of  the  presence  of  the  affection.  There  had  been  no  sensation  to  arrest  his 
attention  other  than  a  slight  roughness  to  the  tongue  and  the  gums  at  the 
location  of  the  disease,  and  which  he  had  noticed  for  several  months.  No 
history  of  syphilitic  infection  could  be  obtained,  and  he  has  never  been  affected 
with  any  form  of  skin  disease.  He  has  been  a  moderate  smoker  since  a  lad, 
having  rarely  exceeded  three  cigars  per  diem. 

Case  5. — History:  This  was  one  of  leucoplakia  buccalis  upon  the  right  and 
left  cheeks,  opposite  the  line  formed  by  the  occluded  teeth,  in  a  retired  gen- 
tleman  of  American  birth,   aged  fifty-two  years,   and   of  fair  health.     (Plate 


Case   TIL     leucoplakia  of  gums,     male,   aged  50  years. 


Case   IV.     leucoplakia  of  gums,     male,   aged  74   years. 


PLATE  VI. 


LEFT    CHEEK 


LEUCOPLAKIA    OF    Clf  ALE,    AGED    52    YEARS. 


LKUCOPLAKIA.  3OI 

VI.)  The  disease  was  discovered  while  making  an  examination  of  his  mouth. 
The  patient  had  not  been  aware  of  any  abnormal  oral  condition,  and  had 
not  noticed  the  presence  of  the  plaques.  There  had  never  been  any  pain  or 
inconvenience  associated  with  the  affection.  He  is  an  habitual  but  not  an 
excessive  smoker  of  good  cigars,  and  uses  liquors  and  wine  in  moderation, 
but  does  not  eat  highly  seasoned  foods.  There  was  no  history  of  syphilis 
or  of  skin  disease.  The  same  advice  was  given  as  in  the  previous  case,  but 
he  refused  to  give  up  the  use  of  tobacco.  This  gentleman's  case  has  now 
been  under  observation  for  over  six  years,  with  no  appreciable  change  in 
the  size  or  condition  of  the  plaques. 

Case  6. — History:  This  was  a  case  of  leucoplakia  linguse  of  eight  years' 
standing,  which  first  appeared  upon  the  dorsum  of  the  tongue  in  small  white 
plaques;  later  two  longitudinal  fissures  appeared,  running  nearly  the  whole 
length  of  the  tongue,  with  several  shorter  ones  radiating  from  these,  which 
were  very  sensitive  to  acids,  pungent  condiments,  acid  fruits,  or  wines.  On 
advice  of  his  physician,  he  stopped  smoking  at  this  time.  Tongue  was  dry 
and  parched  on  waking  in  the  morning.  He  was  treated  at  this  time  for 
nasal  catarrh  and  hypertrophied  turbinated  bones.  This  treatment  gave  great 
relief;  the  nasal  obstruction  being  removed  made  it  possible  for  him  to  breathe 
with  the   mouth  closed,  thus   giving  relief  from  the   dryness   of  the  tongue. 

Three  years  afterward  a  suspicious  ulcer  appeared  upon  the  right  side  of  the 
dorsum  of  the  tongue  near  the  median  line;  this  was  treated  locally  with  silver 
nitrate,  and  iodids  and  mercury  were  administered  constitutionally.  At  this 
time  he  was  thin  and  emaciated,  weighing  only  130  pounds.  The  treatment  im- 
proved his  general  condition;  weight  at  present  time  175  pounds,  and  general 
health  good.  Tongue  presents  fissures  as  above  indicated,  and  the  whole 
dorsum  of  the  tongue  is  covered  with  a  continuous  white  plaque,  which  is 
very  sensitive  to  the  irritation  of  acids,  pungent  condiments,  spirits,  ^tc. 

Treatment  declined. 

Case  7. — History:  This  was  a  case  of  leucoplakia  in  an  American  gentle- 
man fifty  years  of  age,  and  of  robust  health.  Occupation  stockbroker.  The 
disease  was  discovered  while  examining  his  teeth  for  caries.  The  plaques, 
which  were  located  upon  the  right  and  left  sides  of  the  superior  gingivae, 
were  of  the  size  of  a  split  pea,  slightly  raised  above  the  surface,  having 
a  rough,  curdy,  yellowish-white  appearance.  They  were  not  tender  to  the 
touch,  and  had  never  given  any  pain  or  uneasiness,  and  their  presence  had 
not  been  recognized  by  the  patient.  There  was  no  history  of  syphilis  or  of 
any  skin  affection.  He  smoked  from  three  to  five  cigars  each  day.  Was 
advised  to  give  up  tobacco,  but  declined.  There  were  no  other  evidences  of 
the  disease  in  his  mouth. 

Case  8. — History:  This  case  was  one  of  leucoplakia  linguae  buccalis,  etc.,  in 
a  Greek  woman,  married  twenty-six  years  and  aged  sixty  years.  Has  had  no 
children.  Claims  to  have  always  enjoyed  good  health,  and  disclaims  ever 
having  any  skin  eruptions,  mucous  patches  of  the  mouth,  or  any  general  or 
local  disease  requiring  the  attendance  of  a  physician.  The  disease  first  ap- 
peared when  sixteen  years  of  age;  it  followed  a  meal  in  which  she  ate  green 
peppers,  and  was  located  at  that  time  upon  the  dorsum  of  the  tongue.  It  now 
covers  the  roof  of  the  mouth,  the  cheeks,  the  dorsum  and  under  side  of  the 
tongue,  and  the  floor  of  the  mouth;  in  fact,  the  whole  oral  cavity  looks  as  though 
it  were  lined  with  a  layer  of  curdled  milk,  or  as  though  the  whole  mouth  had 
been  cauterized  with  nitrate  of  silver  or  carbolic  acid.     The  power  to  taste 


302  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

foods  had  been  lost,  except  for  salt,  acids,  peppers,  and  pungent  sauces. 
These  substances  caused  a  burning  sensation,  which  was  very  painful.  Exfoli- 
ation of  the  thickened  membrane  upon  the  tongue  frequently  takes  place 
in  patches,  the  uncovered  surface  at  such  times  being  very  sore  and  painful. 
At  the  time  of  the  examination  there  was  no  uncovered  surface  presented. 
She  has  smoked  cigarettes,  three  to  four  each  day,  since  she  was  a  girl  of 
fourteen  or  fifteen  years  of  age. 

This  case  presented  the  most  extensive  involvement  of  the  mucous  sur- 
faces of  the  mouth  that  has  ever  come  under  the  observation  of  the  writer. 
The  opinion  expressed  at  that  time,  in  reference  to  the  cause  of  the  disease, 
was  the  use  of  tobacco. 

Case  9. — History:  This  was  a  case  of  leucoplakia  linguae  and  buccalis  in 
a  Hebrew  gentleman  fifty-six  years  of  age,  who  had  retired  from  business. 
His  health  was  good,  and  had  always  been  so.  The  extent  of  the  disease  was 
very  similar  to  Case  4.  He  was  a  moderate  smoker  of  cigars,  but  never 
used  the  pipe.  There  was  no  history  of  syphilis.  He  was  advised  to  give  up 
the  use  of  tobacco,  but  declined  to  do  so,  as  he  had  never  experienced  any 
inconvenience  from  his  indulgence. 

Case  id. — History:  This  was  a  case  of  leucoplakia  linguae,  the  plaque  being 
situated  upon  the  dorsum  of  the  tongue,  and  the  size  of  a  quarter  dollar. 
This  gentleman  was  forty  years  old,  and  an  inveterate  smoker  of  cigars. 

Case  ii. — This  case  was  one  of  leucoplakia  gingivae  and  buccalis  in  a  man 
past  fifty  3'^ears  of  age,  which  proved  fatal  three  years  after  from  malignant 
degeneration. 

Case  12. — This  was  a  similar  case  in  a  physician  forty-five  years  of  age. 
The  disease,  however,  was  in  its  early  stage,  and  had  not  been  recognized  by 
the  patient.  Immediate  operation  was  demanded,  and  the  diseased  tissue 
removed  down  to  the  bone.  Eleven  years  afterward  there  had  been  no  recur- 
rence. 

Differential  Diagnosis. — The  affections  which  may  be  confounded 
with  leucoplakia  buccalis  are  the  muco-plaques  of  syphilis  and  epi- 
thelioma. In  the  earlier  stages  of  the  disease  such  a  mistake  could 
hardly  be  made,  but  in  the  later  period  of  the  affection  it  might  quite 
easily  be  confounded  with  syphilis  or  epithelioma.  A  three  or  four 
weeks'  course  of  treatment  with  the  iodid  of  mercury  or  potassium 
would  clear  up  the  diagnosis  of  the  former,  while  in  the  latter  it  would 
be  necessary  to  resort  to  the  aid  of  the  microscope  for  a  positive  diag- 
nosis, even  though  there  was  present  the  clinical  evidence  of  enlarged 
lymphatic  glands. 

Pathology. — In  examining  the  histologic  structure  of  the  leu- 
comatous  patches,  whether  ''thick  or  thin,"  a  marked  change  will  be 
noticed  in  the  character  of  the  papillary  layer  of  the  tongue,  the  mucosa 
of  the  lips  and  the  cheeks,  and  in  the  cells  of  the  epidermis.  The 
papillae  of  the  tongue  are  often  very  much  atrophied,  and  occasionally 
have  almost  entirely  disappeared;  while  the  epidermal  layer  has  taken 
on  a  horny  character  more  like  that  of  the  skin.  This  is  true  also  of  the 
epidermal  layer  in  leucoplakia  of  the  mucous  membrane  of  the  lips 
and  the  cheeks.    It  is  also  noticed  that  the  epithelial  processes,  both  of 


LEUCOPLAKIA.  3O3 

the  tongue  and  of  those  portions  of  the  oral  mucous  membrane  affected 
by  leucoplakia,  are  much  shorter  than  is  natural,  and  that  the  corium 
is  infiltrated  with  leucocytes.  In  advanced  stages  of  the  disease  true 
ccll-nests  are  discovered,  which  establishes  the  fact  of  carcinomatous 
degeneration.  How  these  cell-nests  are  formed  in  carcinoma  is  still  a 
disputed  question,  but  it  would  seem  more  than  probable  that  in  carci- 
noma of  the  tongue  and  oral  mucous  membrane  following  leucoplakia, 
the  cell-nests  were  developed  from  traumatic  inclusions  of  epithelial 
cells  following  the  repeated  ulceration  and  healing  of  the  leucomatous 
patches. 

Prognosis. — The  interest  in  the  prognosis  of  leucoplakia  centers 
around  the  tendency  or  the  predisposition  of  the  disease  to  be  followed 
by  malignant  degenerative  changes,  ending  in  the  formation  of  car- 
cinoma. That  such  a  predisposition  exists  there  is  not  a  shadow  of 
doubt. 

In  the  "American  Text-Book  of  Surgery"  we  find  this  statement: 
"Many  cases  of  cancer  of  the  tongue  are  preceded  by  leucoma,  the  so- 
called  psoriasis  of  the  tongue."  Garretson  was  of  the  opinion  that  the 
disease  occupied  the  border-line  between  the  non-malignant  and  the 
malignant  growths.  Le  Dentu  says  it  is  not  at  all  unusual  for  leu- 
coplakia to  become  epitheliomatous.  He  does  not,  however,  consider 
this  to  be  a  general  predisposition  of  the  disease,  but  that  it  is  sometimes 
induced  by  a  tendency  of  leucoplakia  to  degeneration.  Sutton  says : 
"In  a  fair  proportion  of  cases  (20  per  cent.)  epithelioma  of  the  tongue 
is  preceded  by  changes  known  as  leucoplakia  and  ichthyosis ;  and  they 
are  frequently  referred  to  as  pre-cancerous  conditions.  In  the  case  of 
the  cheek,  epithelioma  is  sometimes  preceded  by  a  patch  of  leucoplakia. 
The  disease  often  starts  close  to  the  angle  of  the  mouth  and  extends 
backward  into  the  cheek ;  or  it  begins  in  the  fold  of  mucous  membrane 
between  the  gum  and  the  cheek,  and  occasionally  it  starts  in  the  center 
of  the  cheek,  often  on  a  level  with  the  meeting-place  of  the  crowns  of 
the  upper  and  lower  molar  teeth." 

Senn,  in  speaking  of  carcinoma  of  the  mouth,  says :  "Carcinoma 
of  the  mucous  membrane  of  the  cheek  is  sometimes  preceded  by  a  patch 
of  leucoplakia.  The  influence  of  chronic  irritation  in  producing  carci- 
noma is  well  shown  in  carcinoma  in  this  locality,  as  the  tumor  very 
often  corresponds  in  its  location  with  the  crowns  of  prominent  upper 
and  lower  molar  teeth."  Butlin  states  that  out  of  eighty  cases  of 
cancer  of  the  tongue,  sixteen  were  preceded  by  leucoma.  Park  believes 
leucokeratosis  may  become  the  seat  of  an  epithelioma,  and  its  surgical 
interest  depends  upon  the  frequency  with  which  it  is  followed  by  this 
malignant  growth.  Warren  says  he  "has  seen  but  few  cases  of  leu- 
coma ;  one  of  these  in  a  lady  on  whose  tongue  it  first  appeared  in  youth, 
and  remained  in  the  shape  of  several  large,  brilliant  white  patches,  until 


304  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

old  age,  when  it  disappeared ;  in  another  case,  a  man  forty-three  years 
of  age,  the  tongue  had  been  troublesome  from  childhood ;  the  mucous 
membrane  was  sensitive  and  easily  irritated,  and  it  was  prone  to  inflam- 
matory conditions,  during  which  small  ulcers  appeared.  At  the  age  of 
thirty-four  years  typical  leucoma  appeared,  situated  for  the  most  part 
on  the  right  side  of  the  tongue.  Three  years  later  the  patches  enlarged, 
and  a  warty  growth  formed  in  the  center.  Three  years  after  this  he 
(Warren)  removed  with  the  knife  the  largest  patch,  which  was  about 
the  size  of  a  silver  half-dollar.    This  operation  was  performed  in  June, 

1891.  In  October,  1891,  a  small  epithelial  growth  of  an  apparently 
malignant  nature  appeared  on  the  opposite  side  of  the  tongue.  This 
growth  was  removed  and  found  to  be  typical  cancer.  In  December  a 
similar  growth  was  removed  from  the  tip  of  the  tongue.     In  April, 

1892,  both  growths  having  reappeared,  a  large  portion  of  the  left  side 
and  the  tip  of  the  tongue  were  removed  by  a  wedge-shaped  incision. 
The  disease  never  returned  on  the  tongue,  but  six  months  afterward 
a  glandular  enlargement  was  observed  under  the  left  jaw,  and  the 
patient  died  two  months  later.  The  growth  was  found  to  be  typical 
carcinoma." 

Treatment. — Leucoplakia  of  the  oral  mucous  membrane  is  gen- 
erally exceedingly  rebellious  to  treatment,  and  quite  often  shows  a 
marked  tendency  to  carcinomatous  degeneration ;  therefore  the  meas- 
ures employed  are,  perforce,  largely  those  of  palliation  and  heroic 
operations.  Those  cases,  however,  which  give  a  clear  history  of 
syphilitic  infection  may  be  benefited  by  a  course  of  antisyphilitic  treat- 
ment ;  but  it  may  be  stated  as  a  fact,  that  up  to  the  present  time  no  drug 
has  been  discovered  which,  acting  constitutionally,  has  any  beneficial 
effect  whatever  upon  the  progress  of  leucoplakia. 

The  preventive  measures  which  may  be  instituted  in  the  treatment 
of  leucoplakia  are  the  removal  or  discontinuance  of  all  forms  of  chemic 
and  mechanic  irritation.  Persons  who  suffer  from  an  irritable  and  sen- 
sitive oral  mucous  membrane  should  avoid  chemic  irritants  of  all  kinds, 
particularly  alcohol  in  any  of  its  forms,  acids,  pungent  condiments, 
very  hot  foods  or  drinks,  and  tobacco.  In  persons  already  afflicted  with 
the  disease  such  irritants  stimulate  the  progress  of  the  affection,  and 
should,  therefore,  be  strictly  interdicted.  It  is  much  easier,  however, 
to  advise  a  patient  as  to  what  he  should  do  and  what  he  should  not  do 
than  it  is  to  get  him  to  follow  your  advice.  In  the  early  stage  of  the 
disease — before  it  has  caused  any  real  inconvenience — it  is  very  difficult 
to  get  a  man  who  is  in  the  habit  of  using  spirituous  liquors  or  tobacco 
to  consent  to  give  them  up.  He  feels  that  you  may  be  mistaken,  or  that 
you  are  magnifying  the  danger,  and  hence  decides  not  to  change  his 
habit  of  living,  at  any  rate  for  the  present,  or  until  he  is  convinced  that 
your  advice  is  correct.    Perhaps  he  will  consult  some  other  professional 


LEUCOPLAKIA.  305 

gentleman  wlio  disagrees  with  your  diagnosis  and  laughs  at  your  fears. 
This  reassures  the  patient,  and  he  goes  on  with  his  old  hahit  of  life  for 
months,  perhaps  for  years — in  some  cases  with  im]nniity ;  in  others 
witli  most  disastrous  effects  to  his  comfort  and  his  life. 

The  mechanic  irritants  which  are  most  common  in  the  mouth  are 
usually  associated  with  the  teeth  or  with  artificial  dentures,  such  as 
carious  cavities,  jagged  roots,  fractured  teeth,  salivary  calculus,  rough 
or  ill-fitting  plates,  or  plates  made  of  a  material  which  is  irritating  to 
a  sensitive  mucous  membrane.  All  such  forms  of  irritation  should  be 
at  once  removed,  by  filling  the  cavities,  extracting  the  roots,  giving 
appropriate  treatment  to  the  fractured  teeth,  removing  the  salivary 
calculus  and  carefully  polishing  the  surfaces  of  the  teeth,  while  the 
irritating  artificial  dentures  should  be  replaced  by  others  free  from 
these  objections,  or  discarded  altogether.  Too  much  stress  cannot  be 
laid  upon  these  points  as  a  safeguard  to  the  patient  against  the  devel- 
opment of  the  malignant  form  of  the  disease. 

Local  Treatment. — Nicholson,  who  believes  leucoplakia  to  be  zona 
of  the  oral  mucous  membrane,  considers  local  applications  of  only  tem- 
porary service,  while  the  constitutional  treatment  for  zona  is  often 
entirely  fruitless.  He  recommends,  however,  a  trial  of  the  tincture  ferri 
perchlorid,  25  to  30  minims  (1.3  to  2  grams),  three  times  per  dietn,  as 
in  one  of  his  cases  it  seemed  to  give  relief  from  the  burning  pain,  and 
improved  the  condition  of  the  lingual  epithelium  in  a  remarkable  man- 
ner, when  all  else  had  failed.  Rosenberger  recommends  the  local  appli- 
cation of  pure  balsam  of  Peru  painted  upon  the  patches  with  a  briish, 
allowing  it  to  remain  in  contact  for  from  three  to  five  minutes.  The 
immediate  effect  is  a  slight  burning  sensation  with  an  abundant  saliva- 
tion. These  applications  he  advises  to  be  made  three  times  per  diem. 
In  thirteen  cases  so  treated  great  relief  was  obtained.  The  patches, 
however,  heal  slowly,  a  year  in  some  cases  being  required  to  produce 
a  cure. 

Leistikow  advises  the  local  application  of  the  following  paste : 

Terras  siliceje gr.  xxiv  1 15 

Resorcini gr.  xlviii  3I 

Adipis gr.  viii  |5 

This  he  applies  to  the  afifected  parts  with  a  swab.  From  eight  to 
fourteen  days  afterward  a  contraction  or  shriveling  is  observed,  and  a 
slightly  inflamed  condition  of  the  mucous  membrane,  which  by  the 
application  of  balsam  of  Peru  is  brought  to  a  normal  condition.  Rosen- 
berg reports  a  case  of  leucoplakia  which  had  lasted  for  over  seven 
years,  and  had  resisted  all  the  usual  methods  of  treatment,  in  which 
the  plaques  disappeared  in  a  few  days  after  being  painted  with  a  20 
per  cent,  solution  of  potassium  iodid. 

21 


306  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

In  Case  2,  the  local  application  to  the  plaques  and  the  denuded 
surface  of  the  tongue  of  tinct.  aconite  and  tinct.  iodin,  equal  parts, 
every  other  day  for  two  months,  relieved  all  the  symptoms  except  the 
abnormal  dryness  of  the  tongue,  while  the  denuded  part  healed  and  was 
covered  with  healthy-appearing  papillse.  In  six  of  the  cases  treatment 
was  declined  because  of  the  apparently  trivial  nature  of  the  disease  to 
the  minds  of  the  patients,  while  all  but  two  of  the  others  declined  from 
fear  of  an  operation. 

Palliative  Treatment. — This  consists  of  the  use  of  alkaline  lotions 
or  mouth-washes.  Butlin  recommends  for  this  purpose  in  the  milder 
cases,  potassium  bicarbonate,  15  to  20  grains  in  one  ounce  of  water, 
and  in  the  syphilitic  cases,  chromic  acid,  i  to  2  grains  to  the  ounce  of 
water,  or  a  5-  to  lo-grain  solution  may  be  painted  upon  the  plaques. 
Mercury  bicyanid  is  also  recommended  in  solution  of  i  to  2  grains 
to  an  ounce  of  water,  and  painted  upon  the  plaques.  In  the  severer 
cases,  he  recommends  solutions  of  bicarbonate  of  soda  or  of  boric-  acid. 
He  thinks  mel  boracis  (honey  and  borax)  is  better  suited  to  some 
cases  than  alkaline  solutions,  but  as  a  general  rule,  the  alkaline  solu- 
tions give  greater  relief  in  cases  of  leucoplakia  of  long  standing.  A 
trial  of  these  various  remedies  is  necessary  in  order  to  find  the  one  best 
suited  to  the  individual  case. 

Surgical  Treatment. — In  the  severer  forms  of  the  disease,  radical 
operation  is  the  only  safe  method  to  follow.  The  tendency  of  the  dis- 
ease to  assume  a  malignant  character  should  cause  it  to  be  treated  as 
a  malignant  growth,  and  thorough  extirpation  practiced  at  the  earliest 
moment.  Temporizing  by  the  use  of  caustics  is  worse  than  useless, 
and  most  authors  deprecate  their  use  for  the  reason  that  the  irritation 
seems  to  increase  the  dangers  from  malignant  degeneration.  Garretson 
was  very  emphatic  in  his  denunciation  of  the  use  of  caustics,  of  every 
form,  in  the  treatment  of  this  disease.  Butlin  says :  ''One  general  rule 
holds  good  for  all  cases  of  leucoma,  namely:  not  to  use  caustics. 
Whatever  danger  there  may  be  of  the  development  of  carcinoma  is 
certainly  increased  by  the  employment  of  nitrate  of  silver  and  other 
caustics." 

In  the  fatal  case  of  leucoplakia  buccalis  and  gingivae  reported  by 
the  writer,  the  physician  who  had  charge  of  the  case  treated  it  with 
nitrate  of  silver,  and  later  with  chromic  acid,  with  the  result  of  stimulat- 
ing the  more  rapid  spread  of  the  disease.  On  the  other  hand,  we  may 
contrast  the  results  obtained  by  a  radical  operation  in  an  almost  identical 
case,  also  referred  to  on  a  previous  page,  in  which  a  permanent  cure 
resulted,  as  proved  by  the  fact  that  there  has  been  no  recurrence  after 
a  period  of  over  eleven  years.  The  consensus  of  opinion  obtained 
from  the  perusal  of  the  most  eminent  authorities  is,  that  thorough  and 
complete  extirpation  of  the  diseased  tissue  is  the  only  reliable  method 


LEUCOPLAKIA.  307 

of  treatment,  and  this,  to  be  effective,  must  be  practiced  before  malig- 
nant symptoms  have  developed. 

Perrin,  who  reports  a  case  of  leucoplakia  linguae  and  labialis  with 
papillomatous  epithelial  degeneration,  secured  a  permanent  recovery 
by  the  thorough  extirpation  of  the  plaques  by  surgical  means.  He 
urges  early  and  complete  extirpation  as  the  only  way  by  which  to  avoid 
a  final  transformation  of  the  disease  into  true  epithelial  carcinoma. 
Dubois-Havenith  exhibited  a  case  of  leucoplakia  linguae  upon  the 
left  border  of  the  tongue,  which  was  successfully  treated  by  curetting 
and  the  galvano-cautery.  Butlin  does  not  recommend  the  early  ex- 
cision of  the  plaques  when  the  disease  is  located  in  the  tongue,  unless 
it  "is  very  obstinate,  and  scarcely  at  all  relieved  by  treatment" ;  but  he 
has  no  doubt  of  the  wisdom  of  such  an  operation  in  "indurations, 
warty  growths,  and  very  obstinate  ulcers,  particularly  when  they  pre- 
sent the  slightest  increase  of  induration  about  their  bases.  Such  con- 
ditions must  be  considered  as  young  cancers,  and  must  be  dealt  with  as 
if  they  were  in  truth  cancers."  Hulke  urges  early  excision  of  all 
hard  and  warty  patches  (ichthyosis)  upon  the  tongue  before  they 
attain  a  large  size  as  the  only  means  of  cure. 


CHAPTER    XXXII. 

SURGICAL  TUBERCULOSIS. 

Definition. — Tuberculosis  (Lat.  from  tuherculum,  dim.  of  tuber,  a 
little  swelling.    An  infectious  disease  caused  by  the  Bacillus  tuberculosis. 

Tuberculosis  has  a  widespread,  almost  universal  distribution 
among  the  human  race,  and  it  has  been  estimated  that  more  than  one- 
seventh  of  the  entire  population  of  the  civilized  world  die  from  its 
effects.  Warren  places  the  mortality  as  about  one  to  every  five  deaths, 
and  when  the  fact  is  taken  into  consideration  that  a  considerable  por- 
tion of  those  who  contract  the  disease  finally  recover  their  health,  it 
will  need  no  other  demonstration  to  prove  that  the  disease  is  one  of  the 
most  serious  and  widespread  of  all  the  afflictions  of  mankind.  The 
active  etiologic  factor  in  the  disease  is  the  Bacillus  tuberculosis,  which 
was  discovered  by  Koch  in  1882.  The  discovery  of  this  bacillus,  and 
the  demonstration,  also  by  Koch,  that  by  it  only  could  the  various  phe- 
nomena of  the  disease  be  produced,  have  wrought  great  changes  in  the 
views  held  as  to  the  pathology  of  the  disease,  revolutionizing  a  large 
and  interesting  department  of  surgery. 

Senn  says,  "Tubercular  lesions  furnish  a  most  excellent  illustra- 
tion of  the  origin,  force,  termination,  and  tissue-changes  of  what  is 
known  as  chronic  inflammation,  and  a  description  of  the  histology  of 
a  tubercular  nodule  is  a  description  of  the  pathology  of  chronic  inflam- 
mation. 

"Of  all  the  diseases  which  are  produced  by  micro-organisms,  next 
to  that  of  suppuration,  tuberculosis  is  of  the  greatest  interest  to  the 
surgeon;  of  greatest  interest,  because  it  is  better  understood,  from  the 
bacteriologic  standpoint,  than  are  most  other  surgical  diseases  which 
come  under  his  care,  and  of  no  less  great  importance  on  account  of  its 
frequency." 

"The  discovery  of  Koch  has  also  done  away  with  that  vague  and 
indefinite  term  scrofula,  which  has  been  used  so  long  to  indicate  a 
large  and  ill-defined  class  of  diseases,  for  later  experiments  have 
proved  conclusively  that  they  were  identical  in  all  respects  with  recog- 
nized forms  of  tuberculosis." 

Avenues  of  infection. — The  virus  of  tuberculosis  gains  an  entrance 
308 


SURGICAL   TUBERCULOSIS.  309 

into  the  body  by  various  channels, — through  the  inspired  air,  with  the 
food,  and  by  direct  inoculation.  It  has  been  recognized  since  1826 
that  the  disease  was  transmissible  by  inoculation  through  the  case  of 
Laennec,  who  injured  his  finger  with  a  saw  while  making  an  autopsy 
upon  a  subject  affected  with  tubercular  disease  of  the  vertebrae,  and 
thus  contracted  the  affection.  He  finally  died,  some  years  afterward, 
of  tubercular  disease  of  the  lungs. 

Through  experimentation,  it  was  found  that  tubercular  peritonitis 
could  be  produced  by  the  injection  of  infected  sputa  into  the  peri- 
toneum of  guinea-pigs;  infected  food  produced  tubercular  ulceration 
of  the  mesenteric  glands;  and  the  dried  sputum  when  inhaled  pro- 
duced tubercular  inflammation  of  the  lungs. 

Senn.  in  speaking  of  the  frequency  of  the  disease  and  the  dangers 
of  infection,  says,  "At  least  one  person  out  of  every  seven  dies  of  some 
form  of  tuberculosis.  IMost  of  our  large  hospitals  contain  from 
twenty-five  to  fifty  per  cent,  of  patients  afflicted  with  the  disease. 
Health  resorts  frequented  for  years  by  tubercular  patients  have  be- 
come infected  to  such  an  extent  that  there  is  great  danger  of  the 
whole  population  becoming  exterminated  by  this  disease.  The  sources 
of  infection  in  such  places  have  become  so  numerous  that  it  is  unsafe 
to  breathe  the  air,  to  drink  the  water,  or  to  eat  the  food  prepared  in 
houses  which  for  years  have  been  hot-beds  for  the  Bacillus  tubercu- 
losis, and  by  persons  carrying  the  microbes  upon  every  square  inch 
of  their  surface.  That  whole  communities  and  nations  where  this 
disease  has  been  prevalent  for  centuries  have  not  been  completely 
depopulated  long  ago  is  owing  to  the  fact  that  many  persons  possess, 
from  the  time  of  their  birth,  such  a  degree  of  resistance  to  infection  that 
€ven  direct  infection  by  inoculation  would  prove  harmless." 

Heredity. — It  has  been  assumed  by  certain  writers  that  infection 
might  take  place  through  the  spermatozoa.  Jani  found  bacilli  in  the 
testes  in  five  out  of  eight  phthisical  patients  with  urogenital  tuber- 
culosis ;  in  some  cases  the  bacilli  were  found  in  the  seminal  tubes  and 
in  others  in  the  prostate  gland.  Semb,  Spano,  and  Bugge  have  each 
found  like  conditions.  Walther,  on  the  other  hand,  was  unable  to 
obtain  like  results  in  an  examination  of  nine  cases. 

Gartner  produced  genital  tuberculosis  in  male  guinea-pigs  by  in- 
jecting the  bacilli  into  the  testicles,  but  of  the  seventy-four  young  pigs 
born  of  healthy  females  impregnated  by  the  tuberculous  males  all  re- 
mained free  from  the  disease.  The  mother  pigs,  however,  in  some 
cases  became  infected.  Further  proof  is  therefore  necessary  in  order 
to  settle  the  question  of  the  hereditary  transmission  of  the  disease 
through  the  seminal  fluid. 

The  question  of  hereditary  transmission  of  the  disease  from  the 
mother  to  the  child  through  the  placenta  is  one  which  has  been  ear- 


310  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

nestly  discussed,  Baumgarten  and  others  maintaining  that  the  virus 
may  be  implanted  during  fetal  life,  and  yet  not  show  itself  until  per- 
haps many  years  later. 

Experiments,  however,  upon  pregnant  guinea-pigs  by  inoculation 
failed  to  produce  the  disease  in  their  offspring.  According  to  Warren, 
tuberculosis  in  new-born  children  is  exceedingly  rare,  and  in  those 
cases  reported  with  early  manifestations  of  the  disease  it  is  an  open 
question  as  to  whether  the  disease  may  not  have  been  contracted  from 
the  milk  of  the  mother,  or  in  various  other  ways.  Most  authorities, 
however,  maintain  that  a  predisposition  may  be  inherited  through  a 
peculiar  weakened  condition  of  the  tissues  and  fluids  of  the  body, 
which  makes  them  a  favorable  soil  for  the  growth  and  propagation  of 
the  bacillus. 

In  substantiation  of  this  statement,  it  is  generally  found  that 
tubercular  subjects  have  a  family  history  of  tuberculosis. 

The  pulmonary  tissues  are  probably  the  most  common  avenue 
through  which  the  tubercular  virus  enters  the  system.  The  Bacillus 
tuberculosis  is  very  tenacious  of  life,  and  retains  its  vitality  for  a  con- 
siderable period  even  in  the  dried  state.  These  attributes  make  it  a 
constant  menace  to  the  health  of  those  persons  who  come  in  contact 
with  tubercular  subjects,  unless  the  greatest  care  is  exercised  to 
destroy  the  sputa  and  discharges  while  in  a  moist  state.  The  bacillus 
when  in  a  dried  state  is  capable  of  being  floated  in  the  atmosphere  and 
introduced  into  the  lungs  by  inspiration,  and  therefore  becomes  a 
source  of  great  danger,  as  has  been  frequently  proved  by  experiments 
upon  animals.  It  has  also  been  shown  by  Cornil  that  the  dust  of 
rooms  occupied  by  such  patients  contains  large  numbers  of  bacilli; 
while  Prudden  and  others  have  found  it  in  the  dust  of  the  streets. 
The  linen,  carpets,  and  dishes  used  by  tubercular  subjects  are  also  a 
source  of  danger,  as  is  also  the  communion  cup;  while  the  habit  of 
expectorating  upon  floors  of  public  halls,  street  and  railroad  cars, 
indulged  in  by  so  many  consumptives,  is  an  added  danger  to  the  public 
health  which  should  be  prohibited. 

Fliigge  claims  that  tuberculosis  contracted  from  this  source, — 
namely,  the  dust  from  dried  sputum, — has  never  been  satisfactorily 
proven.  He  believes  the  germs  under  such  conditions  are  not  suffi- 
ciently virulent  to  inoculate  animals,  and  that  it  is  more  than  probable 
that  the  same  is  true  of  man.  The  greatest  danger  in  his  opinion  is 
from  the  moist  germs  which  may  be  readily  disseminated  in  the 
atmosphere  from  the  air  expelled  from  the  lungs  of  tuberculous  subjects 
in  the  acts  of  speaking,  coughing,  sneezing,  etc.,  the  bacilli  floating  in 
the  tiny  drops  of  moisture  contained  in  the  expired  breath. 

Experiments  conducted  by  Fliigge  upon  susceptible  animals  by 
means  of  a  fine  spray  charged  with  the  bacilli  and  blown  into  their 


SURGICAL   TUBERCULOSIS.  3 II 

faces,  similar  to  the  spray  expelled  by  a  consumptive  in  the  act  of 
coughing-  with  open  month,  were  successful  in  inoculating  such  ani- 
mals. A  most  convincing  proof,  however,  was  afforded  by  the  inocu- 
lation and  death  of  a  laboratory  attendant  in  charge  of  the  spray  inocu- 
lation experiments  who  neglected  to  use  the  preventive  precautions 
imposed  upon  him.  Dogs  which  were  kept  in  an  opposite  end  of  the 
laboratory  for  another  purpose  were  also  infected  from  the  spray  float- 
ing in  the  atmospliere. 

Certain  cases  of  pulmonary  tuberculosis,  according  to  Bollinger, 
are  not  due  to  the  inhalation  of  the  bacilli,  but  to  metastasis  from  dis- 
ease in  other  parts  of  the  body.  Tuberculosis  of  the  upper  extremities 
is  most  liable  to  produce  secondary  infection  of  the  lungs.  Tubercular 
disease  of  the  wrist  is  a  well-known  cause  of  pulmonary  consumption. 

The  alimentary  tract  is  also  a  channel  through  which  tubercular 
infection  may  take  place.  It  has  been  frequently  demonstrated  that 
the  intestinal  tract  of  animals  can  readily  be  infected  by  feeding  them 
with  tuberculous  food.  In  the  human  subject  primary  tuberculosis  of 
the  intestines  produced  from  infected  food  is  not  an  uncommon  occur- 
rence. Milk  from  tuberculous  cows,  and  water  infected  with  the 
virus,  have  long  been  recognized  as  sources  of  danger.  The  viability 
of  the  bacillus  is  somewhat  remarkable,  Cornil  having  demonstrated 
that  it  could  live  in  sterilized  water  at  the  ordinary  temperature  for 
seventy  days. 

Roasted  meat,  if  infected  with  tubercle,  may  be  a  source  of  consid- 
erable danger  on  account  of  the  central  portions  not  being  subjected 
to  the  same  high  degree  of  temperature  during  the  process  of  cooking. 
The  Bacillus  tuberculosis  is  destroyed  if  subjected  to  a  temperature  of 
212°  F.  for  four  minutes,  but  the  spores  will  resist  a  much  higher 
temperature,  and  for  a  longer  time. 

Secondary  tuberculosis  of  the  intestines  is  due  to  auto-infection, 
as  the  infected  sputum  is  frequently  swallowed.  The  investing  mem- 
brane or  capsule  of  the  bacillus  is  not  readily  acted  upon  by  the  gastric 
juice,  consequently  it  arrives  in  the  intestinal  tract  in  an  uninjured  con- 
dition, where  it  attacks  the  Peyer's  patches,  or  the  solitary  glands. 
Later,  the  mesenteric  glands  become  infected,  and  also  the  peri- 
toneum. In  women,  the  infection  frequently  takes  place  through  the 
genital  tract. 

The  mucous  membranes  of  the  mouth,  nose,  and  pharynx  are  also 
channels  through  which  infection  may  take  place.  The  disease  may 
be  transmitted  from  one  individual  to  another  by  kissing,  or  by  the 
drinking-vessel  or  spoon  used  by  a  person  suffering  frorn  pulmonary 
tuberculosis.  The  tongue  spatula,  or  the  instruments  and  hands  of 
the  dentist,  may  become  a  source  of  considerable  danger,  unless  they 
are   carefully  washed  and   sterilized  after  being  used  upon   such   a 


312  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

patient.  As  much  care  should  be  taken  in  this  direction  with  instru- 
ments, etc.,  as  would  be  given  to  them  after  having  been  used  upon  a 
syphilitic  subject. 

The  skin  is  sometimes  the  avenue  for  the  introduction  of  the 
tubercular  virus.  Bollinger  thinks  this  channel  of  infection  is  under- 
estimated. Direct  inoculation,  however,  through  the  skin  does  not 
play  a  very  important  role  in  the  causation  of  the  disease.  All  cases 
of  primary  tuberculosis  of  the  skin,  however,  are  the  result  of  inocu- 
lation. The  bacillus  does  not  seem  to  have  the  power  to  enter  the 
skin  like  the  pus-producing  cocci.  Infection,  how-ever,  may  occur 
through  superficial  wounds  and  slight  abrasions  of  the  cutis.  A  con- 
siderable number  of  cases  have  been  reported  during  the  last  few  years, 
— enough,  it  would  seem,  to  establish  the  fact  that  tubercular  infection 
may  take  place  in  man  by  absorption  of  the  virus  through  slight 
abrasions  and  superficial  wounds  of  the  skin. 

Tubercular  infection  occasionally  takes  place  in  those  whose  duty 
it  is  to  perform  autopsies  upon  bodies  of  persons  who  have  died  of 
tuberculosis,  as  in  the  case  of  Laennec,  just  mentioned. 

Watson  Cheyne  also  reports  such  a  case  in  a  student  who  injured 
the  finger  at  the  base  of  the  nail.  A  wart  formed,  which  remained  as 
an  ulcer  after  three  years  of  treatment.  Later  an  abscess  formed  upon 
the  back  of  the  hand,  and  finally  the  finger  was  amputated.  Six  years 
after  the  injury  he  died  of  tubercular  meningitis. 

All  portions  of  the  body  do  not  appear  to  be  equally  open  to 
infection.  Certain  tissues  and  organs  seem  to  have  a  predisposition 
for  the  disease,  viz:  the  lungs,  the  lymphatic  glands,  and  the  bones. 
The  face  and  head  are  peculiarly  liable  to  infection.  There  is,  how- 
ever, hardly  a  tissue  of  the  body  which  under  favorable  conditions 
may  not  become  the  seat  of  primary  tubercular  infection,  or  escape 
secondary  infection  w^hen  the  virus  is  disseminated  through  the 
general  infection. 

The  lymphatic  system  is  often  the  avenue  through  which  remote 
parts  of  the  body  may  become  infected.  The  lymphatic  glands,  how- 
ever, on  the  other  hand,  exert  a  protective  influence  against  the  dis- 
semination of  the  disease,  by  retarding  the  progress  of  the  bacilli  or 
indirectly  accomplishing  their  destruction. 

The  bacilli  may  gain  an  entrance  to  the  general  circulation  either 
through  the  thoracic  duct,  after  having  traversed  the  last  chain  of 
glands  of  the  lymphatic  system,  or  by  the  breaking  down  of  tubercles 
in  the  immediate  vicinity  of  blood-vessels,  the  contents  being  dis- 
charged directly  into  the  blood-current.  Eventually  the  bacilli  are 
conveyed  to  some  arteriole  or  capillary  where  they  become  lodged, 
and  the  conditions  are  established  w^hich  favor  the  development  of 
miliar}'  tubercle. 


SURGICAL   TUBERCULOSIS. 


313 


Pathology. — The  lesion  which  is  produced  by  the  growth  of  the 
Bacillus  tuberculosis  in  the  tissues  is  known  as  tubercle.  It  is  variously 
designated  as  the  miliary  or  gray  tubercle  or  nodule. 

In  appearance  it  is  a  grayish,  translucent  mass  from  i-io  to  2  mm. 
in  diameter,  and  firmly  imbedded  in  the  surrounding  tissues.  It  is 
made  up  of  an  aggregation  of  cells  which  are  microscopic  in  size,  and 
is  the  product  of  a  minute  point  of  inllanimation  established  by  the 

Fig.  120. 


Tuberculosis— Reticular  Form— Lung,  showing  Fibrous  Reticulum,  Lymphoid  and  Giant 

Cells.    X  50. 

presence  of  the  tubercular  bacillus.  Larger  masses  are  formed  by  the 
■coalescence  of  neighboring  tubercles,  producing  the  so-called  tuber- 
€ulous  infiltratious. 

The  histologic  elements  which  make  up  a  typical  primary  tubercle 
are  three  groups  of  cells, — the  round  or  lymphoid  cells,  the  epithelioid 
cells,  and  the  giant  cells,  and  a  delicate  reticulum  of  connective  tissue 
which  is  more  dense  at  the  outer  surface  of  the  tubercle  than  toward 
the  center.      (Fig.  120.) 

Senn  classes  the  lymphoid  cells  as  leucocytes,  and  accounts  for  their 


314 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


presence  in  the  tubercle  by  the  inflammatory  action  of  the  specific 
microbe  upon  the  walls  of  the  capillary  vessels.  These  cells  are  found 
most  abundantly  at  the  periphery  of  the  tubercle,  but  are  scattered 
about  through  all  the  cellular  elements,  and  they  are  most  numerous 
when  the  inflammatory  process  is  acute.  These  facts,  he  claims,  are 
convincing  proofs  of  the  inflammatory  nature  of  tuberculosis. 

Fig.  121. 


fe^l 

■>-   4IJ  ■■.-  .^  '     ".-^ — ~r — ^T- 

■"..-I'i..---  ■     r*     ' 

Lymphoid  cells. 

."!,•-■.■'." -'"■--'•■A'- 

Giant  cells. 

Giant  cells. 

mm 

'^<^^^^^^i!t:^^^^''  • 

■    ■       '~>     '    '     "'     r  ■        V' 

■i^n 

■:-.f^^-m^- 

Giant  celL 


Giant  cell. 


Acute  Tuberculosis— Small  Nodule,  showing  many  Giant  Cells.    Lung.    X  50. 


The  epithelioid  cells  are  so  designated  by  their  resemblance  to  epi- 
thelial cells.  These  cells  were  first  described  by  Rindfleisch.  Klebs 
calls  them  platycytes.  Cheyne  is  authority  for  the  statement  that  the 
epithelioid  cells  are  the  most  characteristic  cellular  elements  of 
tubercle,  and  are  more  constant  than  the  giant  cells.  They  are  prob- 
ably derived  from  the  epithelial  tissue  (epithelium  and  endothelium)^ 
and  are  about  two  or  three  times  as  large  as  the  white  blood- 
corpuscles;  in  shape  they  are  round  or  elongated;  in  structure  finely 
granular,  and  they  contain  one  large  or  several  smaller  nuclei.     They 


SURGICAL    TUr.ERCULOSIS.  315 

are  scattered  all  through  the  tubercles,  but  are  found  in  the  greatest 
numbers  grouped  around  the  giant  cells  and  at  the  periphery  of  the 
nodule. 

The  giant  cells,  according  to  Senn,  are  hyperplastic  epithelial  cells, 
and  consequently  are  derived  from  the  same  kind  of  tissue.  They  are 
a  characteristic  feature  of  tubercular  nodules,  one  or  more  being  found 
in  the  center  of  each.  (Fig.  121.)  This  feature  enables  the  micro- 
scopist  to  make  an  almost  positive  diagnosis,  even  though  the  tubercle 
bacilli  cannot  be  found  in  a  nodule. 

The  giant  cell  in  structure  is  finely  granular,  and  contains  mul- 
tiple nuclei.  These  nuclei  occupy  chiefly  a  position  at  the  periphery 
of  the  cell,  and  are  arranged  with  their  long  diameters  radiating  from 
the  center.  Occasionally  they  are  arranged  in  the  form  of  a  crescent 
at  one  end.  During  the  progress  of  the  disease  the  giant  cells  become 
progressively  fibrous  at  their  periphery,  which  gradually  encroaches 
upon  the  protoplasmic  central  portion.  The  bacilli  are  found  in  the 
giant  cells;  also  between  and  in  the  epithelioid  cells,  and  in  the  later 
stages  in  the  round  cells. 

Degeneration  of  the  nodule  begins  first  in  the  center  of  the  giant 
cells,  and  as  this  central  degeneration  progresses  the  bacilli  disappear 
in  this  portion  of  the  cell,  though  they  may  still  be  found  at  the 
periphery. 

The  giant  cells  of  tubercular  tissue  are  similar  to  the  cells  found 
in  normal  tissue  (particularly  in  bone  and  the  medullary  tissue).  They 
are  also  found  in  the  tissues  surrounding  foreign  bodies  which  are 
undergoing  the  process  of  encystment.  Giant  cells  have  the  power  of 
ameboid  movement,  which  enables  them  to  take  up  into  their  proto- 
plasm small  bodies,  such  as  micro-organisms,  disintegrated  blood- 
corpuscles,  etc. 

The  reticulum,  according  to  Warren,  is  not  usually  a  new  forma- 
tion, but  is  composed  of  the  pre-existing  intercellular  connective 
tissue.  Cell-growth  being  most  active  in  the  center,  a  certain  amount 
of  pressure  is  exerted  from  within  outward,  causing  a  thickening  of  the 
fibrous  elements,  which  sometimes  amounts  almost  to  the  formation 
of  a  capsule.  Sometimes  the  reticulum  seems  to  be  formed,  to  a  large 
extent,  by  the  processes  of  the  epithelial  cells.  As  the  vascular  supply 
is  generally  very  slight,  the  smaller  vessels  soon  disappear  altogether. 
In  consequence  of  this,  the  vitality  of  the  nodule  is  soon  greatly  low- 
ered, resulting  in  the  death  of  the  cellular  elements,  or  coagulation 
necrosis,  followed  by  granular  disintegration  and  fatty  degeneration  of 
the  cells,  producing  the  condition  known  as  caseous  degeneration.  The 
tubercular  bacillus,  by  its  specific  action,  or  through  its  ptomaines,  also 
appears  to  exert  an  influence  which  brings  about  a  chemical  change  in 
the  cells. 


3i6 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


The  process  of  caseation  (Fig.  122)  begins  in  the  center  of  the 
nodule,  and  may  gradually  extend  so  as  to  affect  the  entire  mass. 
When  caseous  degeneration  is  extensive,  ulceration  may  take  place,  or 
abscesses  may  form.  Sometimes  calcareous  materials  are  deposited  in 
the  mass,  resulting  in  what  is  known  as  calcification. 

Arrest  of  the  disease  frequently  takes  place  in  the  lungs,  and  occa- 
sionally in  the  lymphatic  glands,  by  the  processes  of  caseation  and 
calcification. 

Fig.  122. 


Tubercle. 


Tuberculosis— Caseous  Tubercle.    Lung.    X  5°- 


Calcification  is  nature's  method  of  preventing  the  local  extension 
of  the  disease,  and  guarding  against  the  infection  of  surrounding 
tissues  or  of  the  general  system. 

Liquefaction  of  the  caseous  material,  and  the  formation  of  ab- 
scesses, is  the  more  common  termination  of  the  cheesy  degeneration. 
The  material  thus  formed  has  always  heretofore  been  regarded  as  pus; 
recent  investigations,  however,  have  established  beyond  a  doubt  that 
it  is  the  product  of  a  retrograde  metamorphosis  of  tissue,  and  not  true 
pus. 


SURGICAL   TUBERCULOSIS.  317 

The  tubercular  or  so-called  cold  abscess  contains  a  fluid  which  to 
the  unaided  eye  resembles  pus,  but  when  subjected  to  examination  by 
the  microscope  it  presents  none  of  the  characteristic  histologic  ele- 
ments of  pus. 

The  effects  produced  by  the  presence  of  the  tubercular  bacillus 
in  the  tissues  are  always  those  of  chronic  inflammation,  and  this  in- 
variably results  in  the  production  of  granulation-tissue.  The  embry- 
onal cells  of  which  the  granulation-tissue  is  composed  seem  under 
certain  conditions  to  act  as  a  wall  of  protection  against  the  encroach- 
ment of  the  disease  upon  the  surrounding  tissues. 

The  secondary  infection  of  tubercular  abscesses  with  the  pus-mi- 
crobes causes  a  breaking  down  of  this  wall  of  protection,  and  the 
patient  incurs  the  dangers  of  local  septic  infection  and  a  general 
dissemination  of  the  tubercular  condition. 

Garre  is  of  the  opinion  that  many  cases  of  tubercular  ulcerations 
and  abscesses  are  the  result  of  a  mixed  infection.  The  examination  of 
the  contents  of  cold  abscesses,  and  of  the  liquefied  caseous  material  of 
tuberculous  cavities  in  bone,  revealed  no  pus-microbes,  not  even  in 
those  which  pursue  a  rapid  course.  He  therefore  believes  it  is  possible 
in  many  cases  of  suppuration  following  the  tubercular  process,  that 
the  pus-microbes  had  ceased  to  exist  before  examination  for  their 
presence  was  instituted. 

AVhen  the  specific  bacillus  meets  with  a  sufficient  resistance  from 
the  tissues  surrounding  the  nodule,  it  eventually  exhausts  the  nutrient 
material  found  in  the  granulation,  and  either  dies  or  assumes  a  latent 
condition.  The  granulation-tissue  is  then  converted  into  cicatricial 
tissue,  and  the  local  manifestations  of  the  disease  disappear. 

If,  on  the  other  hand,  the  bacilli  are  present  in  sufficient  numbers 
to  cause  destruction  of  the  embryonal  cells  wdth  coagulation,  caseation, 
and  liquefaction  of  the  infected  tissue,  a  spontaneous  cure  may  still  be 
possible,  by  absorption  of  the  fluid  portion  and  the  encystment  of  the 
solid  debris.  If  bacilli  or  spores  remain  behind,  there  will  always  be 
great  danger  of  a  relapse  in  this  disease. 


CHAPTER    XXXIII. 

SURGICAL  TUBERCULOSIS  (Continued). 

Tuberculosis  of  Bone. 

With  the  definite  statement  of  the  proposition  that  tuberculosis 
is  an  infectious  disease  caused  by  the  Bacillus  tuberculosis;  that  it  is 
characterized  by  the  production  of  a  pecuHar  tissue  designated  as 
tuberculous,  and  of  certain  inflammatory  products  which  appear  in  the 
form  of  nodules  or  miliary  tubercles,  and  as  a  diffuse  infiltration,  and 
which  rapidly  undergo  caseous  degeneration,  we  may  now  turn  to  the 
consideration  of  those  tubercular  conditions  which  are  found  affecting 
the  bones,  the  skin,  and  the  mucous  membrane,  as  of  greatest  interest 
from  the  standpoint  of  the  oral  surgeon  and  the  dentist. 

Tuberculosis  of  the  bone  is  one  of  the  most  common  of  tubercu- 
lar affections,  those  of  the  lungs  and  lymphatic  glands  only  being  more 
frequent.  Tubercular  disease  of  the  bones  occurs  very  often  in  chil- 
dren and  youth, — in  fact,  the  great  majority  of  cases  occur  before  adult 
life.  Dollinger  reported,  as  a  result  of  investigation  into  the  family 
history  of  two  hundred  and  fifty  cases  of  tubercular  disease  of  the 
bones,  that  in  more  than  one-third  of  them,  one  or  more  of  the  imme- 
diate ancestors  had  suffered  from  pulmonary  tuberculosis,  usually  the 
grandparents.  He  therefore  comes  to  the  conclusion  that  the  influ- 
ence of  the  tubercular  virus  must  be  exerted  through  several  genera- 
tions before  the  normal  resistance  of  osseous  structures  is  so  far  weak- 
ened that  they  become  a  suitable  field  for  the  lodgment  and  develop- 
ment of  the  tubercular  bacillus,  and  that  in  the  inherited  (?)  form,  or 
predisposition  to  tuberculosis,  the  lungs  are  attacked  in  the  first  gener- 
ation, and  the  bones  in  the  second. 

The  most  common  location  of  the  disease  is  in  the  epiphyseal  ends 
of  the  long  bones,  but  it  is,  however,  frequently  found  in  the  short 
bones  of  the  hand  and  the  foot,  and  occasionally  in  the  flat  and  irreg- 
ular bones,  as  the  vertebrae,  the  ribs,  the  scapula,  the  ilium,  the  bones 
of  the  cranium,  of  the  nose,  and  of  the  face.  The  disease  is  most  fre- 
quently found  in  the  cancellated  structure  of  the  bone,  but  it  may  occur 
in  the  compact  tissue,  and  in  any  portion  of  the  bone. 

The  disease  may  be  primary  or  secondary  in  its  origin. 

318 


SURGICAL    TUBERCULOSIS.  3^9 

It  is  probable,  however,  that  only  a  very  small  portion  of  the  cases 
•  of  tubercular  nodules  of  the  bones  are  primary  in  their  origin;  the  great 
majority  of  them  are  secondary  to  disease  of  the  lymphatic  glands,  of 
the  bronchial  or  mesenteric  group,  infection  having  taken  place  through 
the  mucous  membrane  of  the  respiratory  or  alimentary  tract,  the  bacilli 
being  transported  through  the  circulation,  and  deposited  in  the  bone. 
Landerer,  according  to  Warren,  examined  post  mortem  one  hundred 
and  fifty  cases  of  tubercular  and  bone  diseases,  and  with  one  or  two 
exceptions  found  tubercular  disease  of  the  bronchial  glands  that  evi- 
dently antedated  the  bone-affection. 

Primary  tuberculosis  of  bone  when  it  does  occur  is  doubtless  the 
•result  of  inoculation,  through  wounds  and  abrasions,— in  other  words, 
-of  traumatic  origin. 

Authorities  differ  as  to  the  influence  of  traumatic  injuries  in  pro- 
-ducing  tubercular  disease  of  the  bones.     Senn  quotes  Volkmann  as 
saying  that  traumatisms  which  produce  tubercular  disease  of  the  bones 
are  afways  slight,  and  often  insignificant.     Senn  himself  believes  that 
•only  in  a  small  per  cent,  of  tubercular  disease  of  bones  can  the  disease 
be  traced  to  a  traumatic  origin.     Warren  says  the  great  majority  follow 
slight  contusions  and  sprains.     Experience  teaches  that  tuberculosis  of 
bone  rarely  if  ever,  even  in  tubercular  subjects,  follows  a  severe  injury 
or  fracture  of  the  bone,  doubtless  on  account,  as  Senn  expresses  it,  of 
the  active  cell-proliferation  going  on  about  such  an  injury  that  neutral- 
izes the  pathogenic  action  of  the  bacilli  which  might  reach  the  seat 
•of  the  injury  with  the  extravasated  blood.     But  in  injuries  less  severe, 
the  same  cell-activity  does  not  exist,  the  tissues  are  disabled  for  a 
brief  period  by  the  damage  which  they  have  sustained,  and  during 
this  time  they  are  in  a  less  resistant  state  through  the  deleterious 
action  of  the  bacterial  ptomaines.     They  then  become  a  favorable  soil 
for  the  development  of  the  bacillus,  and,  as  already  shown,  in  individ- 
uals predisposed  to  tuberculosis  the  seeds  of  the  disease  may  already 
be  present  in  the  lymphatic  glands,  and  only  waiting  for  favorable  con- 
ditions to  begin  their  active  growth.     Such  a  point  of  injury  might 
therefore  establish  a  focus  for  the  development  of  the  bacilli,  the  forma- 
tion of  nodules,  and  later  a  more  or  less  extensive  tubercular  osteitis. 

It  very  rarely  happens  that  tuberculosis  of  bone  occurs  during  the 
progress  of  tubercular  disease  of  the  lungs,  but  pulmonary  tubercu- 
losis and  diffuse  miliary  tuberculosis  can  frequently  be  traced  to  tuber- 
cular disease  of  the  bone.  The  frequency  with  which  this  occurs  is 
explained  by  the  intimate  relationship  existing  between  the  tubercular 
nodule  in  bone  and  the  blood-vessels,  thus  rendering  systemic  infection 
almost  certain.  The  tendency  of  tubercular  disease  of  the  glands,  if 
allowed  to  take  its  course,  is  toward  bone  tuberculosis,  and  later,  to 
pulmonary  or  diffuse  miliary  tuberculosis. 


320  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

Volkmann  says  that  a  child  suffering  from  glandular  tuberculosis- 
has  a  good  chance  of  becoming  the  subject  of  osseous  tuberculosis  dur- 
ing adolescence,  and  to  die  of  pulmonary  tuberculosis  before  reaching 
the  age  of  thirty. 

A  peculiarity  of  tubercular  disease  of  the  bone  is,  that  it  generally 
begins  at  that  point  where  the  growth  is  the  most  rapid  and  greatest  in 
amount.  In  the  long  bones  this  is  at  the  epiphyseal  ends;  in  the  flat 
and  irregular  bones  at  the  outer  borders.  When  infection  takes  place 
it  is  practically  never  direct,  and  when  the  disease  makes  its  appearance 
it  is  only  an  evidence  that  the  germs  of  the  disease  were  already  present 
in  some  other  organ.  When  the  bacilli  are  present  in  the  blood-cur- 
rent they  sometimes  become  localized  in  the  terminal  branches  of  an 
artery,  particularly  in  partially  developed  bone,  by  being  arrested  in 
their  progress,  and  the  lumen  of  the  vessel  is  obliterated  by  the  pres- 
ence of  a  minute  embolus  of  granulation-tissue  containing  bacilli,  or 
the  caliber  of  the  vessel  may  be  gradually  decreased  until  it  is  finally 
obliterated  by  the  formation  of  a  mural  thrombus  around  bacilli  which 
have  found  a  lodgment  upon  the  inner  walls  of  the  vessel.  In  young 
persons  the  new  vessels  which  are  forming  in  partially  developed  bone 
are,  by  their  imperfect  structure,  and  the  irregularity  of  their  contour, 
the  most  favorable  in  location  and  conditions  for  the  arrest  of  floating 
granular  particles  and  bacilli.  These  conditions  would  therefore  seem 
to  be  a  strong  predisposing  cause,  and  an  explanation  of  the  frequency 
with  which  tuberculosis  of  bone  occurs  at  the  point  of  greatest  growth. 

The  relative  frequency  with  wdiich  tuberculosis  occurs  in  the  bones 
of  the  head  and  face,  as  compared  with  other  bones  of  the  body,  is  one 
of  considerable  interest.  Quoting  from  the  tables  of  Schmallfuss,  in 
Senn's  "Principles  of  Surgery,"  we  find  Billroth  places  the  bones  of  the 
cranium  and  the  face  third  in  the  list,  with  a  percentage  of  thirteen. 
Jafife  gives  the  bones  of  the  cranium  the  eighth  place,  with  a  per- 
centage of  three;  but  no  reference  is  made  to  cases  affecting  the  bones 
of  the  face.  Schmallfuss  also  places  the  bones  of  the  cranium  in  the 
eighth  place,  with  a  percentage  of  four,  but  also  mentions  no  cases 
affecting  the  bones  of  the  face.  If  Billroth's  cases  of  tubercular  disease 
of  the  bones  of  the  cranium  did  not  average  higher  than  those  of  the 
other  authorities  named,  it  would  be  fair  to  say  that  the  ratio  of  cases 
of  the  disease  in  the  bones  of  the  face  would  be  nine  per  cent. 

Tuberculosis  of  the  bones  of  the  cranium  is  found  most  frequently 
in  the  bones  of  the  ear  and  the  mastoid  process.  After  these,  it  is  found 
chiefly  in  the  frontal  and  temporal  bones. 

The  bones  of  the  face  which  are  most  often  the  seat  of  the  disease 
are  those  of  the  nose,  the  superior  maxillae,  the  malar,  and  the  palate. 
The  inferior  maxilla  is  rarely  affected  by  the  disease. 

Tttbercidosis  of  Bone,  or  Caries  of  Bone,  is  an  ulcerative  process;  a 


SURGICAL   TUBERCULOSIS.  321 

molecular  death  of  bone,  due,  as  wc  have  already  learned,  to  the  pres- 
ence of  tubercular  nodules  formed  by  the  action  of  the  specific  bacillus 
upon  the  bone-tissue  in  which  it  has  been  deposited. 

The  disease  always  begins  as  an  intercellular  osteitis,  of  low, 
chronic  type,  and  Volkmann  says  these  chronic  tuberculous  inflamma- 
tions of  bone  have  a  tendency  to  form  in  the  ends  of  the  long  bones 
near  the  joints,  just  as  pulmonary  tuberculosis  does  in  the  apex  of  the 
lung. 

The  clinical  history  of  tuberculosis  of  bone,  as  well  as  the  appear- 
ance of  the  tissues,  with  the  unaided  power  of  the  eye,  and  also  micro- 
scopically, is  the  same  as  that  found  in  typical  cases  in  other  tissues 
of  the  body.  Warren  describes  these  appearances  as  follows:  "On 
making  a  section  of  the  bone  the  tubercular  nodule  appears  as  a  well- 
defined  mass  of  reddish  gray,  yellowish  white,  or  pure  yellow  color. 
The  surrounding  bony  tissue  is  usually  red  and  hyperemic,  and  the 
trabeculse  may  be  somewhat  thickened.  The  cancellous  spaces  are 
devoid  of  fat-cells,  and  they  contain  a  swollen  semi-fibrous  material. 
With  a  microscope  the  miliary  tubercles  are  seen  at  the  periphery  of 
the  nodule,  its  center  being  composed  of  broken-down  cheesy  material. 
The  size  of  these  nodules  varies  greatly.  As  they  grow,  the  tubercular 
virus  attacks  the  trabeculge,  leading  to  their  absorption,  the  bone 
becomes  softened,  and  breaks  up  into  a  mass  of  greasy,  cheesy  mate- 
rial, containing  crumbling  fragments  of  bone-tissue.  When  complete 
softening  has  taken  place,  the  material  of  which  the  nodule  is  composed 
becomes  puriform,  and  it  may  be  washed  away,  leaving  a  cavity  lined 
with  granulation-tissue.  In  case  the  trabeculas  are  not  completely  de- 
stroyed in  the  infected  part,  the  cancelli  between  them  become  filled 
with  cheesy  debris ;  as  the  vitality  of  the  part  is  destroyed,  granulation- 
tissue  is  formed  around  the  diseased  mass,  and  absorption  of  the  con- 
necting trabeculse  occurs ;  the  spongy  sequestrum  which  is  thus  formed 
separating  from  the  living  bone.  These  sequestra  are  quite  small,  and 
are  more  or  less  globular  in  form.  The  surrounding  bone  becomes 
somewhat  thickened,  and  the  interstices  are  filled  with  gray  fibrous 
tissue,  or  eburnation  of  the  bone  may  in  some  cases  take  place.  When 
the  nodule  has  softened  completely  into  pus — liquefied — the  surround- 
ing bone  is  covered  by  a  tubercular  membrane,  or  its  surface  is  infil- 
trated with  granulation-tissue,  which  usually  contains  miliary  tubercles 
on  its  inner  aspect,  affording,  nevertheless,  protection  to  the  adjacent 
bone.  These  small  sequestra — spiculse — lie  firmly  imbedded  in  a 
thick  layer  of  blue-gray,  transparent  granulation-tissue,  dotted  with 
yellow  spots.  Large  amounts  of  pus  rarely  accumulate  around  these 
nodules." 

The  crucial  test,  however,  of  the  tubercular  character  of  all  chronic 
inflammatory  bone  affections,  is  the  presence  of  the  specific  bacillus. 


322  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

In  many  cases  there  is  great  difficulty  in  finding  the  bacillus,  but 
Cheyne  attributes  this  to  the  fact  that  they  are  more  numerous  in  the 
first  stage  of  the  disease,  and  that  their  numbers  decrease  in  the  later 
stages,  or  rapidly  pass  into  the  spore  formation.  There  are  also  diffi- 
culties in  staining  them,  which  are  not  understood,  for  sometimes  in 
double  staining  some  will  take  red  and  others  blue,  which  he  thinks  is 
probably  due  to  the  dififerent  stages  of  their  development. 

Tubercular  abscesses  are  formed  by  the  breaking  down  into 
caseous  material  of  confluent  masses  of  tubercle  in  the  center  of  a 
nodule.  This  material  becomes  infiltrated  with  fluids  and  leucocytes. 
A  cavity  is  thus  formed  which  contains  fluid,  fatty  material,  fragments 
of  disorganized  cells,  and  leucocytes,  surrounded  by  granulation-tissue 
filled  with  tubercles. 

Cold  abscess  is  the  result  of  the  burrowing  of  pus,  forming  large 
ca""  .ies,  into  which  tuberculous  cavities  at  neighboring  points  may  have 
d.jcharged  after  liquefaction  has  taken  place.  The  pus  which  these 
abscesses  contain  is  so  characteristic  that  it  would  never  be  mistaken 
after  it  had  once  been  seen.  It  is  of  a  pale  white  color,  much  thinner 
than  the  pus  of  acute  abscesses;  it  frequently  contains  masses  of 
cheesy  material  resembling  coagulated  casein,  and  for  this  reason  is 
termed  grumous.  Sometimes  it  is  mingled  with  blood,  when  it  will 
be  a  dirtv  brown  color.  Small  particles  of  bone  are  not  infrequently 
present,  which  feel  to  the  fingers  like  grains  of  sand.  The  presence  of 
bacilli  can  rarely  be  demonstrated  with  the  microscope  in  such  pus. 
Cultures,  however,  yield  the  characteristic  microbe. 

The  tubercular  membrane,  as  it  is  termed,  was  first  described  by 
Volkmann.  It  is  an  opaque  membrane,  several  millimeters  in  thick- 
ness, of  violet  gray  or  yellowish  brown  color,  scantily  supplied  with 
blood-vessels  on  its  inner  aspect,  containing  innumerable  clusters  of 
miliary  tubercles,  which  are  supported  by  a  matrix  of  coagulated  fibrin. 
It  is  easily  scraped  off  with  the  finger,  or  removed  by  washing  with  a 
stream  of  water  from  the  irrigator,  or  peels  o&  during  an  operation. 
This  membrane  is  considered  by  Volkmann  as  an  absolutely  certain 
diagnostic  sign  of  the  tuberculous  character  of  the  abscess. 

Burrowing  of  the  pus  is  a  much  more  rare  condition  in  tubercular 
disease  of  the  bones  of  the  cranium  and  of  the  face  than  it  is  in  the  long 
bones  and  in  the  vertebra,  as  the  former  are  not  so  deeply  covered  by 
soft  tissues. 

Symptoms  and  Diagnosis. — In  this  disease  the  general  symptoms 
are  often  of  little  value  as  an  indication  of  the  presence  or  the  extent 
of  the  local  afifection,  as  it  frequently  occurs  that  patients  with  quite 
extensive  tuberculosis  of  the  bones  may  give  every  indication  of 
robust  health.  Konig,  who  is  authority  on  all  matters  relating  to 
tuberculosis,  has  called  attention  to  the  fact  that  in  nearlv  all  cases  of 


SURGICAL    TUBERCULOSIS.  323 

even  limited  local  tuberculosis  there  will  be  found  a  slight  evening  rise 
of  temperature.  Senn  says  that  an  evening  rise,  if  not  more  than 
one-half  of  a  degree  F.,  if  continued  for  weeks,  should  indicate  a  care- 
ful search  for  a  local  tubercular  focus. 

Aiic7iiia,  if  progressive,  is  always  an  unfavorable  symptom,  and 
is  the  result  either  of  the  extension  of  the  disease  to  other  important 
organs,  or  of  exhausting  discharges,  growing  out  of  secondary  infec- 
tion with  the  pus-producing  micro-organisms.  Such  infection  is 
always  announced  by  a  sudden  and  high  temperature,  with  the  accom- 
panying signs  of  septic  infection. 

Paiiij  of  a  more  or  less  mild  character,  is  an  almost  constant  symp- 
tom. It  is  rarely,  however,  so  intense  as  in  acute  suppurative  osteo- 
myelitis, where  the  tension  from  the  accumulated  pus  is  sometimes  very 
great.  In  tubercular  inflammation,  the  primary  exudation  is  always 
scanty,  and  the  product  of  the  inflammation  is  principally  granulation- 
tissue  formed  from  the  pre-existing  cells, — fixed  tissue-cells;  the  bone 
in  the  immediate  neighborhood  becomes  porous,  thus  allowing  the  pus 
to  penetrate  the  bone,  and  relieving  the  tension  that  would  otherwise 
exist,  and  mitigating  the  pain  to  a  greater  or  less  extent.  When  the 
pain  is  severe,  it  indicates  an  acute  inflammatory  condition.  The  pain 
is  also  intermittent,  and  ahvays  more  severe  at  night.  Another  peculi- 
arity of  the  pain  is,  that  it  is  often  referred  to  some  remote  part,  as,  for 
instance,  in  hip-joint  disease,  the  pain  is  referred  to  the  knee,  and  in 
tuberculosis  of  the  vertebrse  the  suftering  is  usually  experienced  in  the 
pit  of  the  stomach,  or  some  part  of  the  abdomen  supplied  by  nerves 
having  their  exit  from  the  spinal  canal  near  the  diseased  vertebrae. 

Tenderness  is  usually  present  over  a  tubercular  focus  in  the  inte- 
rior of  the  bone,  which  can  be  readily  located  by  palpation.  Swelling 
is  usually  absent  in  the  early  stage  of  the  disease,  or  until  the  external 
compact  tissue  yields  to  the  pressure  from  within  or  is  perforated  and 
forms  a  soft,  boggy,  circumscribed  swelling  beneath  the  periosteum. 
This  condition  is  not  always  indicative  of  the  presence  of  pus.  The 
swelling  may  seem  to  fluctuate,  but  is  misleading  on  account  of  the 
character  of  the  granulation-tissue  beneath,  which  gives  it  a  pseudo- 
fluctuation.  Such  granulating  foci  have  many  times  been  incised 
under  the  belief  that  they  w^ere  abscesses.  When  caseation  takes  place 
in  the  tubercular  focus  before  perforation  of  the  periosteum  occurs,  the 
surrounding  tissues  become  rapidly  infected,  and  a  tubercular  abscess 
is  the  result. 

The  color  of  the  skin  is  not  changed  over  a  tubercular  focus  in 
bone,  or  over  a  tubercular  abscess,  until  the  granulations  have  perme- 
ated the  deeper  portions  of  the  skin,  or  until  the  liquefied  caseous  mate- 
rial has  so  far  reached  the  surface  as  to  have  only  the  skin  for  a  cover- 
ing, when  it  presents  a  dusky  red  hue.     This  is  due  to  an  impaired 


324  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS, 

circulation;  the  skin  becomes  thinner  and  thinner  from  atrophic 
changes  induced  by  pressure,  destruction  occurring  in  the  deeper  por- 
tions, until  finally  it  ruptures  spontaneously,  and  the  contents  are 
discharged. 

Diiferential  Diagnosis. — As  a  means  of  differential  diagnosis,  a 
doubtful  swelling  may  be  explored  (antiseptically)  by  a  strong,  spear- 
pointed  steel  needle, — or,  if  such  an  instrument  is  not  at  hand,  a  heavy 
hypodermic  needle  will  serve  the  purpose.  Such  an  instrument  will 
usually  enter  the  bone,  which  has  been  reduced  in  density  by  the  action 
of  the  chronic  inflammation,  provided  osteo-sclerosis  has  not  taken 
place.  In  the  active  stage  of  tuberculosis  of  bone,  the  osseous  tissue 
becomes  softened  and  porous,  so  that  sometimes  the  needle  readily 
penetrates  it.  If  the  needle  meets  with  any  considerable  resistance,  it 
may  be  rotated  as  it  advances;  when  it  reaches  the  granulating  focus  or 
caseous  mass,  resistance  is  suddenly  lost,  and  the  needle  may  be  passed 
through  to  the  opposite  side.  The  size  of  the  cavity  may  be  approxi- 
mately determined  by  this  method. 

In  tubercular  disease  of  the  bones  of  the  face,  it  is  also  necessary  to 
differentiate  between  syphilis,  sarcoma,  cysts,  and  chronic  indurations 
located  in  the  alveolar  processes.  The  great  majority  of  chronic 
inflammations  of  bones  are  due  to  tuberculosis.  Senn  claims  that  95 
out  of  every  100  cases  are  due  to  this  cause.  This,  as  a  general  state- 
ment, is  quite  correct,  but  it  would  need  to  be  somewhat  modified  in 
applying  it  to  the  bones  of  the  face.  A  bacteriologic  examination  is 
necessary  to  establish  a  positive  diagnosis. 

Prognosis. — The  prognosis  in  cases  of  tuberculosis  of  bone  is  more 
favorable  than  if  it  were  located  in  a  joint,  or  in  the  skin,  the  lym- 
phatic glands,  or  any  of  the  internal  organs.  Tuberculosis  of  bone  is 
sometimes  spontaneously  arrested,  and  a  complete  cure  takes  place, 
just  as  occurs  in  certain  cases  of  pulmonary  tuberculosis.  This  is 
brought  about  by  the  establishment  of  favorable  conditions  of  the 
health,  which  give  the  system  control  of  the  disease,  and  limitations  are 
defined,  sometimes  before  caseation  has  taken  place.  If,  however, 
caseous  material  has  been  formed,  and  it  can  be  removed  surgically, 
the  prognosis  is  still  favorable.  As  already  stated  in  preceding  pages, 
an  individual  who  has  suffered  from  osteo-tuberculosis  in  childhood  or 
youth  is  always  liable,  under  favoring  conditions,  to  reinfection  with 
the  disease  from  the  spores  of  the  bacilli  which  may  remain  indefinitely 
in  the  tissues  where  they  have  been  deposited. 

In  osteo-tuberculosis  of  the  face,  the  part  most  liable  to  be  affected 
is  the  infraorbital  ridge.  Tubercular  inflammation  occurring  in  this 
region  is  most  common  in  children.  Warren  has  seen  it  in  adults. 
The  disease  progresses  very  slowly,  being  marked  by  swelling  or  full- 
ness of  the  region;  suppuration  finally  occurs,  the  skin  may  rupture 


SURGICAL   TUDERCULOSIS.  S^S 

Spontaneously,  one  or  more  sinuses  are  formed,  the  discharge  becomes 
chronic,  and  may  continue  for  months,  terminating  in  unsightly  scars 
and  ectropion  of  the  lower  eyelid.  A  case  of  this  character  in  a  boy  of 
seven  years  came  under  the  care  of  the  writer  about  ten  years  ago,  in 
which  the  entire  orbital  plate  of  the  maxillary  bone  and  a  portion  of  the 
bodv  of  the  bone  were  destroyed,  producing  ectropion  and  closure  of 

the  nasal  duct. 

The  malar  bone  is  occasionally  the  seat  of  the  disease.  Warren 
mentions  a  case  in  which  the  disease  in  this  location  caused  an  exten- 
sive suppuration,  and  finally  terminated  in  ankylosis  of  the  jaw.  Oste- 
otomy was  performed  a  year  after  the  old  sinuses  had  closed. 

The  bones  of  the  nose  are  not  infrequently  the  location  of  the  dis- 
ease.    The  infection  may  be  primary,  or  it  may  be  secondary  to  tuber- 
culosis of  the  skin  (lupus),  or  to  the  disease  in  the  mucous  membrane. 
In  this  way,  also,  the  floor  of  the  nasal  fossa  may  become  involved,  and 
tubercular  caries  of  the  hard  palate,  with  perforation,  occur;  or  the 
disease  may  have  its  origin  in  the  hard  palate,  and  upon  perforating 
the  floor  of' the  nares,  extend  to  the  bones  of  the  nose,  resulting  in  loss 
of  tissue,  and  sometimes  considerable  deformity,  by  reason  of  the 
removal  of  the  support  to  the  soft  tissues.     Du  Castel  has  reported  a 
case  of  tuberculosis  affecting  the  bony  palate  in  a  man  who  consulted 
him  for  a  perforation  of  the  hard  palate,  which  was  at  first  thought 
to  be  due  to  svphilis.    A  more  careful  examination  revealed  an  ulcera- 
tion upon  the  roof  of  the  mouth  near  the  palatal  root  of  the  second 
superior  right  molar  tooth,  covered  by  a  soft  coat  and  surrounded  by 
miliarv  granulations.     There  was  no  history  of  syphilis  and  no  scars 
or  other  manifestations  that  could  be  attributed  to  this  disease.     Ex- 
amination of  the  chest  showed  the  man  to  be  suffering  from  pulmonary 
tuberculosis  in  an  advanced  stage.    The  margins  of  the  perforation  m 
the  hard  palate  were  covered  with  granulations  which  upon  examma- 
tion  were  found  to  contain  numerous  tubercles  with  Koch  bacilli.    In 
this  form  of  the  disease  there  is  danger,  therefore,  of  confounding  it 
with  syphilitic  manifestations  in  the  same  locality.     It  is  better  where 
doubt  exists  as  to  the  diagnosis  to  place  the  patient  upon  anti-syphilitic 
treatment  for  two  or  three  weeks,  when  the  diagnosis  will  most  likely 

be  made  clear. 

The  alveolar  process  is  also  occasionally  the  seat  of  the  affection, 
the  disease  generallv  being  located  through  the  chronic  inflammatory 
process  established  bv  devitalized  teeth.  Garretson  mentions  a  case 
of  this  character  having  its  origin  at  the  seat  of  a  chronic  abscess 
caused  bv  a  pulpless  superior  lateral  incisor,  which  resulted  in  caries 
of  nearly  the  entire  upper  jaw,  and  required  an  extensive  operation 
for  the  removal  of  the  diseased  bone. 

The  writer  recently  operated  upon  a  little  boy,  five  years  of  age, 


326 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


for  extensive  caries  of  the  alveolar  process  of  the  right  upper  jaw 
caused  by  the  irritation  of  two  badly  decayed  and  devitalized  deciduous 
molars.  The  bone  was  so  soft  as  to  be  easily  scraped  away  with  the 
curette,  while  the  pus  was  filled  with  cheesy  masses.  Fig.  123  showS  a 
giant  cell,  etc.,  from  tubercular  disease  of  the  angle  of  the  lower  jaw. 

Treatment. — Patients  who  are  suffering  from  tubercular  disease 
of  the  bones  need,  first  of  all,  tonic  and  supporting  treatment,  nourish- 

FiG.  123. 


Giant  cell. 


Tuberculosis  of  Angle  of  Inferior  Maxilla,  showing  Giant  Cell.    )<  800. 

ing  food,  out-door  air,  and  moderate  exercise;  change  of  climate,  sea- 
bathing, or  a  sea-voyage  are  often  of  more  real  value  than  drugs. 

The  local  treatment  of  tuberculosis  of  the  bones  of  the  face  com- 
prehends mainly  a  radical  operation.  This  consists  of  removing, 
under  antiseptic  precautions,  the  entire  focus  of  infected  tissue,  and  the 
measure  of  success  will  depend  largely  upon  the  stage  of  the  disease 
when  the  operation  is  made.  Success  is  more  likely  to  be  assured  in 
the  granulating  form  of  the  disease  if  caseation  has  not  taken  place. 
Operations  should  not  be  delayed  after  a  positive  diagnosis  has  been 


SURGICAL    TUBERCULOSIS. 


327 


established,  that  adjacent  tissues  may  not  become  involved,  and  that 
general  infection  may  be  prevented. 

Ftg.  124. 


The  Cryer  Surgical  Engine  in  its  Latest  Form. 

In  operations  upon  the  bones  of  the  face  and  jaws,  the  writer  has 
found  the  surgical  engine  and  round  burs  the  most  satisfactory  instru- 
ments for  the  removal  of  carious  bone.    Figs.  124,  125,  126,  127  illus- 


328 


SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

Fig.  125. 


M 


Trephine  and  Typical  Burs  for  Surgical  Engine 


Fig.  126. 


Two  forms  of  Cryer's  spiral  osteotome,  one  (a)  with  dentate,  and  one  {/>)  with  plain  cutting-edges, 
c  shows  the  osteotome  mounted,  with  its  button-like  guard  for  cuttingfenestra,etc.,in  thebrain-case 
without  injury  to  the  subjacent  membranes,     a  and  d  are  twice  the  size  of  cutting-tool ;  c  is  full  size. 


SURGICAL    TUBERCULOSIS. 


329 


trate  the  improved  surgical  engine,  trephine,  burs,  osteotome,  etc. 
The  curette  and  chisel,  however,  answer  a  good  purpose,  if  the  engine 
is  not  to  be  obtained.  The  delicacy  and  speed  with  which  the  bone  can 
be  removed  with  the  engine  and  burs  places  these  instruments  in  the 
front  rank  of  this  kind  of  bone  surgery. 

The  softened  or  osteoporotic  bone  must  be  thoroughly  removed, 
and  the  surface  carefully  examined,  to  see  that  healthy  tissue  has  been 
reached;  as  an  added  precaution,  the  surface  may  be  punctured  at  sus- 
picious places  with  a  sharp-pointed  steel  probe,  as  occasionally  this 

Fig.  127. 


Cryer's  Circular  Saw  with  Adjustable  Guard  for  Cutting  the  Brain-case  to  any  Pre- 
determined Depth. 


instrument  will  reveal  a  concealed  focus  of  infection  that  can  then  be 
removed.  Senn  recommends  that  the  surface  be  punctured  with  a 
sharp-pointed  Paquelin  cautery  to  the  depth  of  a  few  lines,  as  this  pro- 
cedure will  destroy  some  of  the  bacilli  that  might  remain,  and  also 
incite  a  plastic  inflammation  that  would  effectually  resist  the  patho- 
genic action  of  such  bacilli  as  w^ere  still  present.  Too  much  stress 
cannot  be  laid  upon  this  part  of  the  operation.  The  cavity  is  then  to 
be  dried,  dusted  with  iodoform,  packed  with  iodoform  gauze ;  the  edges 
of  the  wound  sutured,  except  at  the  lower  angle,  where  space  is  left 
for  the  removal  of  the  packing  and  for  drainage.  Senn  fills  the  cavity 
with  antiseptic,  decalcified  bone-chips,  suturing  the  periosteum  sepa- 
rately in  operations  upon  the  long  bones,  and  claims  excellent  results. 
Such  a  procedure  ought  to  be  available  in  the  treatment  of  certain 
cases  of  tuberculosis  of  the  superior  maxillary  and  malar  bones  having 
external  openings,  and  where  loss  of  bone-tissue  would  cause  a  serious 
deformity. 

Tubercular  abscesses  are  treated  by  incision,  and  the  removal  of 
the  tubercular  membrane  and  granulation,  and  irrigation  with  an 
aqueous  solution  of  iodin.     The  primary  lesion  must  also  be  found  and 


330  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

removed.  Aspiration  and  injections  of  solutions  of  iodoform  and  gly- 
cerol are  rarely  practiced  in  connection  with  tubercular  abscesses  in 
the  region  of  the  face,  for  the  very  good  reason  that  abscesses  requir- 
ing such  treatment  are  exceedingly  rare  in  connection  with  the  bones 
of  this  region.  Most  cases  of  tubercular  abscess  associated  with  the 
face  can  be  treated  more  successfully  by  radical  operation. 


CHAPTER    XXXIV. 

SURGICAL  TUBERCULOSIS  (Continued). 
TUEERCULOSIS  OF  THE  SkIN  AND  MuCOUS  MeMBRANE. 

Tuberculosis  of  the  Skin,  or  Lupus  Vulgaris. — Until  the  pos- 
itive demonstration  by  Koch  that  lupus  was  a  form  of  tuberculosis  of 
the  skin,  there  was  a  very  wide  difiference  of  opinion  among  the  various 
authorities  as  to  the  real  nature  and  origin  of  the  disease.  The  French 
and  English  authors  were  quite  generally  agreed  that  it  was  one  of  the 
manifestations  of  scrofula,  and  that  it  was  composed  of  granulation- 
tissue.  The  German  authorities  differed  very  greatly  as  to  the  causa- 
tion of  the  affection.  Virchow  did  not  believe  it  to  be  a  manifestation 
of  scrofula,  and  classed  it  with  the  granulomata.  Heuter  considered  it 
to  be  a  fungous  inflammation,  and  that  the  specific  cause  was  capable 
of  producing  miliary  tuberculosis  when  introduced  into  the  tissues. 
Volkmann  classed  it  with  those  diseases  which  are  characterized  by  the 
production  of  granulation-tissue.  Baumgarten  afifirmed  that  the  ab- 
sence of  caseous  material  in  lupus  was  an  evidence  of  its  non-tuber- 
culous character,  while  Friedlander  stoutly  maintained  that  lupus  was  a 
tubercular  disease  of  the  skin,  identical  in  its  histologic  structure  with 
other  forms  of  the  affection,  and  presenting  the  same  characteristic 
miliary  tubercles. 

At  the  present  time  there  seems  to  be  no  doubt  that  lupus,  and 
many  other  forms  of  skin-disease,  are  tubercular  in  their  nature,  and 
directly  caused  by  the  presence  in  the  tissues  of  the  Bacillus  tubercu- 
losis. 

Koch  not  only  demonstrated  the  presence  of  the  bacillus  in  lupus 
nodules,  but  he  succeeded  in  producing  a  pure  culture  of  the  microbe 
from  lupus  tissue,  which  in  every  respect  resembled  that  produced  from 
recognized  tubercular  tissue,  while  with  the  fifteenth  generation  of  the 
bacillus  from  this  culture  he  successfully  inoculated  five  guinea-pigs  by 
subcutaneous  injection,  producing  typical  tuberculosis  in  each  of  them. 

Before  this  time,  however,  clinical  observation  and  the  accumu- 
lation of  anatomical  proofs  had  demonstrated  that  in  all  probability 
lupoid  affections  were  of  tubercular  origin,  or  that  there  was  a  very 
close  relation  between  them  and  tuberculosis,  but  the  positive  proofs 

331 


332  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

were  lacking  until  the  discovery  of  Koch.  The  experiments  of  Koch 
have  since  been  repeated  many  times  by  other  scientists  to  prove  the 
identity  of  the  bacillus  found  in  lupus  tissue  and  tuberculosis,  with  al- 
most uniformly  positive  results. 

Tuberculosis  of  the  skin  is  often  associated  with  other  forms  of 
tuberculosis.  Brock  found  79  per  cent,  of  the  cases  examined  by  him 
were  complicated  with  other  forms  of  tuberculosis.  Rassdnitz  found 
that  30  per  cent,  out  of  two  hundred  and  nine  cases  were  associated 
with  other  manifestations  of  tubercular  disease.  Besnier  reported 
that  21  per  cent,  of  the  cases  of  lupus  that  came  under  his  observation 
eventually  died  of  phthisis.  Pontoppidan  said  that  50  to  75  per  cent, 
of  his  patients  suffering  from  lupus  gave  additional  evidence  of  other 
forms  of  tuberculosis. 

Tuberculosis  of  the  skin  may  be  primary  or  secondary  in  its  origin. 

All  forms  of  primary  tubercular  disease  of  the  skin  are  doubtless 
the  result  of  inoculation  with  the  Bacillus  tuberculosis.  It  is  some- 
what remarkable,  however,  that  taking  into  account  the  frequency  with 
which  abrasions  and  slight  wounds  occur  upon  the  exposed  portions 
of  the  skin,  and  the  many  ways  in  which  the  dangers  of  infection  with 
the  tubercular  virus  are  presented,  the  primary  form  of  the  disease  does 
not  occur  with  much  greater  frequency. 

It  is  a  well-known  fact  that  lupus  occurs  most  frequently  upon 
those  parts  of  the  body  which  are  most  constantly  exposed  to  injury 
and  infection.  Lupus  is  found  most  frequently  in  the  skin  of  the  nose, 
face,  eyelids,  ears,  and  hands,  locations  which  are  not  afforded  protec- 
tion by  either  the  hair  or  clothing,  and  which  are  constantly  exposed  to 
slight  injuries,  to  the  lodgment  of  bacilli  floating  in  the  atmosphere, 
and  to  direct  inoculation  with  the  virus  from  almost  innumerable 
sources.  The  secondary  form  of  the  disease  is  usually  found  in  pa- 
tients suffering  from  advanced  tuberculosis,  and  is  a  manifestation  of  a 
general  diffusion  of  the  affection  to  the  skin  and  mucous  membrane,  or 
of  auto-infection  in  persons  suffering  from  primary  tuberculosis  of  the 
lungs. 

Pathology. — As  primary  tuberculosis  of  the  skin  is  always  the  di- 
rect result  of  inoculation,  the  pathologic  changes  are  therefore  always 
first  made  manifest  at  the  point  of  infection.  These  manifestations 
consist  of  the  formation  of  nodules  which  contain  all  of  the  histologic 
elements  of  true  tubercular  nodules,  viz:  giant  cells,  epithelioid  cells, 
leucocytes,  and  the  Bacillus  tuberculosis ;  caseous  material  is,  however, 
rarely  found.  This  is  accounted  for,  in  all  probability,  as  suggested 
by  Senn,  from  the  location  of  the  tubercular  product  so  near  to  the 
surface  of  the  skin,  and  also  because  the  granulation-tissue  soon  be- 
comes the  seat  of  suppuration,  due  to  secondary  infection  from  the 
pus-microbes.    By  the  aggregation  of  these  nodules,  and  the  infiltration 


SURGICAL   TUBERCULOSIS.  333 

of  the  surrounding  cellular  tissues,  the  lesion  gradually  spreads,  and  by 
the  coalescence  of  the  infiltrated  portions  there  is  established  a  more  or 
less  extensive  area  of  tubercular  tissue. 

In  those  cases  where  the  break  in  the  continuity  of  the  tissue  at  the 
point  of  the  infection  has  been  restored,  the  cell  proliferation  may  be 
so  abundant  as  to  cause  a  swelling  resembling  a  papillomatous  growth 
and  covered  with  a  scaly  epidermis,  the  result  of  excessive  formation 
and  exfoliation  of  epidermal  tissue.  Whenever  the  underlying  granu- 
lation-tissue becomes  exposed,  septic  infection  immediately  takes  place 
from  the  introduction  of  the  pus-microbes,  and  the  process  of  destruc- 
tion of  the  granulation-tissues  is  hastened  by  the  action  of  the  septic 
organisms  and  their  ptomaines.  Ulceration  immediately  takes  place, 
the  break  in  the  continuity  of  the  skin  increases  in  size  and  rapidity, 
commensurate  with  the  formation  of  granulation-tissue  by  the  action 
of  the  Bacillus  ttiberculosis  and  the  development  of  new  nodules  in  the 
immediate  vicinity  of  the  ulceration. 

In  some  forms  of  lupus  the  infection  remains  superficial,  and  only 
the  outer  layers  of  the  skin  become  involved;  in  others  the  destructive 
process  strikes  deeper  and  deeper,  involving  the  muscles,  fascia,  peri- 
osteum, and  bone,  simulating  very  closely  the  clinical  features  of  ma- 
lignant neoplasms.  This  form  of  the  disease  not  infrequently  attacks 
the  face,  destroying  the  nose,  eyelids,  lips,  and  a  greater  portion  of  the 
cheeks,  leaving  the  face  much  like  that  of  a  skeleton. 

Symptoms  and  Diagnosis. — ^Tuberculosis  of  the  skin  is  found  most 
frequently  in  middle  life;  no  age,  however,  is  exempt  from  it.  It  is 
occasionally  found  in  little  children  and  persons  of  advanced  age. 

The  disease  is  usually  described  as  a  neoplastic  affection  of  the 
skin,  or  of  the  contiguous  mucous  membrane,  of  highly  chronic  char- 
acter and  type,  manifested  in  the  form  of  slowly  developing  small  red- 
dish-brown or  yellowish-red  nodules,  or  centers  of  infiltration.  These 
nodules,  when  further  developed,  tend  to  rise  above  the  surface,  and 
form  papules  or  tubercles.  The  spread  of  the  disease  is  by  peripheral 
extension  and  the  formation  of  new  centers,  while  the  older  ones  disap- 
pear by  gradual  resorption,  or  ulceration  takes  place,  resulting  in  the 
formation  of  disfiguring  scars. 

The  varying  degree  to  which  the  corium  and  the  papillary  layers 
of  the  skin  are  involved  gives  rise  to  the  differences  in  the  clinical 
appearances  of  the  disease,  and  the  terms  applied  to  them.  The  ordi- 
nary classification  is  as  follows: 

Lupus  Maculosus. 

Lupus  Exfoliativus. 

Lupus  Exulcerans. 

Lupus  Serpiginosus. 

Lupus  Hypertrophicus. 


334  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

Another  classification  of  the  various  forms  of  the  disease,  also 
based  upon  the  clinical  appearances,  is  as  follows: 

Non-ulcerative,  or  lupus  non-exedens; 

Ulcerative,  or  hipus  exedens; 

Exfoliative,  or  liipiLs  exfoliativus; 

Hypertrophic,  or  lupus  hypertrophicus-(W3Lgner). 

Lupus  Maculosus  is  characterized  by  the  formation  in  the  skin  of 
minute  yellow-brown  nodules  or  patches,  usually  of  pin-head  size,  more 
or  less  transparent,  and  covered  with  epidermis.  The  color  is 
changed  to  a  lighter  shade  under  pressure.  The  nodules  appear  to  lie 
just  beneath  the  surface,  their  outline  being  well  defined.  The  epi- 
dermis covering  the  patch  is  usually  smooth,  but  it  is  occasionally  scaly 
or  shiny.  The  papules  commonly  appear  in  clusters,  and  as  they  grow 
they  approach  one  another,  finally  becoming  confluent  and  forming 
nodules  of  considerable  size. 

The  most  characteristic  feature  of  the  lupus  patch  is  its  soft  con- 
sistence. It  is  much  less  firm  than  the  surrounding  skin,  and  offers 
little  resistance  to  the  end  of  a  blunt  probe  when  pressed  upon  it.  The 
normal  skin  will  entirely  resist  such  pressure,  while  the  lupus  patch 
gives  way  and  the  probe  is  buried  in  the  mass.  Lupus  maculosus  is 
the  simple  form  of  the  affection,  and  is  always  the  first  stage  of  the  dis- 
ease. It  also  appears  at  the  periphery  of  old  patches,  and  is  often  the 
first  indication  of  a  relapse  in  old  cicatrices.  This  constitutes  lupus 
non-excedens,  or  the  non-ulcerative  variety.  When  ulceration  does 
not  take  place,  the  nodules  may  rem.ain  stationary  for  an  indefinite 
period,  or  a  spontaneous  cure  may  take  place  by  cicatrization. 

Lupus  Exfoliativus  is  a  later  stage  in  the  progress  of  the  disease, 
characterized  by  central  degeneration  of  the  matured  nodule,  caseous 
change,  and  cicatrization.  The  skin  becomes  rough,  scaly,  and  fis- 
sured; exfoliation  takes  place,  leaving  the  skin  considerably  thinned  or 
atrophied,  which  thus  easily  becomes  folded  or  wrinkled. 

Lupus  Exulcerans.  Occasionally  the  lupus  process  terminates  by 
a  sort  of  subcutaneous  cicatrization.  Usually,  however,  the  disease 
progresses  to  ulceration.  Before  ulceration  takes  place  the  surface  is 
usually  covered  with  thickened  epidermis,  which  can  be  scraped  off  in 
white  scales.  Ulceration  begins  over  the  center  of  the  nodule,  and 
extends  toward  the  periphery,  attacking  the  new  nodules  almost  as 
rapidly  as  they  are  formed.  The  ulcerative  process  is  hastened  by  the 
secondary  infection  with  the  pus-producing  micro-organisms,  which 
enter  the  granulation-tissue  at  the  border  of  the  ulcer.  Repair  by  cica- 
trization and  the  ulcerative  process  often  go  on  at  the  same  time  in  a 
lupus  patch.  Repair  is  more  likely  to  occur  if  the  tubercular  process 
has  been  confined  to  the  skin,  than  when  it  has  progressed  beyond 
this  tissue.     This  constitutes  the  ulcerative  variety,  or  lupits  exedens. 


SURGICAL  TUBERCULOSIS.  335 

Lupus  Serpiginosus  is  but  another  form  of  hipus  exedens,  in 
which  the  process  of  repair  by  cicatrization  and  epidermization  pro- 
gresses in  an  irregular  form.  Healing  may  take  place  in  the  center  of 
a  lupus  patch,  or  in  a  segment  of  the  periphery,  while  at  other  points 
the  morbid  process  continues,  and  the  disease  creeps  on,  followed  by 
the  scar,  and  giving  rise  to  irregular  gyrate  forms.  When  the  ulcerative 
process  accomplishes  its  work  of  destruction  with  greatest  rapidity, 
penetrating  to  muscle  and  bone,  and  destroying  them,  it  is  termed 
lupus  vorax. 

Lupus  Hypertrophicus  is  a  form  of  the  disease  in  which  there  is 
an  exuberant  formation  of  tissue  which  produces  a  papillary  growth. 
These  papillary  growths  are  probably  derived  from  the  granulation- 
tissue  which  has  been  covered  by  epithelium  in  the  process  of  healing, 
and  may  remain  as  permanent  warty  growths,  or  at  other  times  become 
soft  and  fungous,  with  a  tendency  to  bleed.  When  this  form  of  the 
disease  is  located  in  the  lower  extremities,  the  formation  of  hypertro- 
phied  tissue  is  sometimes  so  excessive  as  to  cause  a  very  considerable 
enlargement  of  the  limbs,  producing  a  species  of  elephantiasis.  This 
latter  form  never  remains  as  a  permanent  condition,  but  sooner  or 
later,  sometimes  after  years,  the  hypertrophied  tissue  breaks  down, 
followed  by  ulceration  and  cicatrization. 

Tuberculosis  of  the  Skin  of  the  Face. — The  first  manifestations 
of  lupus  in  the  face  are  the  so-called  primary  efflorescences  found  upon 
one  or  both  cheeks,  upon  the  nose,  or  upon  the  cheek  and  nose,  in  the 
form  of  a  dull-colored  maculation  upon  the  skin,  often  unnoticed  for  a 
long  time;  or  it  may  appear  in  the  form  of  a  minute  nodule;  or  a  thick- 
ened purplish  patch,  the  size  of  the  finger-nail.  The  disease  spreads,  as 
already  described,  by  extension  from  a  single  patch,  or  by  multiple 
lesions.  The  contraction  of  the  cicatrices  formed  by  the  process  of 
healing  often  results  in  great  disfigurement  of  the  face,  in  some  cases 
causing  ectropion  of  the  eyelid  or  lip.  The  nose  often  becomes  very 
much  reduced  in  size  after  the  ravages  of  the  disease  have  subsided,  the 
point  being  markedly  sharpened,  though  occasionally,  according  to 
Hyde,  the  point  becomes  bulbous,  flattened,  livid,  and  knobbed,  with  a 
thickened  septum  and  distorted  alse. 

The  upper  lip  is  frequently  involved  when  the  disease  is  situated 
upon  the  nose,  marked  at  first  by  considerable  swelling,  followed  by 
fissures  which  are  prone  to  bleed  and  the  formation  of  crusts  on  the 
granulating  surface.  Considerable  deformity  usually  follows  the  heal- 
ing of  tubercular  ulceration  of  the  upper  lip,  the  mouth  being  some- 
times reduced  to  a  mere  slit  or  hole  in  the  face,  with  little  power  to 
open  or  close  it. 

Tuberculosis  of  the  Mucous  Membrane  of  the  Mouth. — 
Tubercular  disease  of  the  mucous  membrane  of  the  mouth  is  generally 


336  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

found  as  an  extension  of  the  affection  from  the  neighboring  infected 
integument.  In  the  great  majority  of  cases  it  is  secondary  to  tuber- 
culosis of  the  skin,  proceeding  from  this  tissue  to  the  mouth,  extending 
to  the  mucous  hning  of  the  hp,  the  gum,  the  hard  palate  and  the  velum 
palati,  or  the  pharynx,  or  the  conjunctiva.  Primary  tuberculosis  of 
the  mucous  membrane  is  comparatively  of  rare  occurrence.  When  it 
is  remembered  that  the  oral  cavity  is  often  the  seat  of  superficial  injur- 
ies and  pathologic  changes  which  form  excellent  points  for  infection 
with  the  bacillus,  it  seems  a  wonder  that  the  primary  form  of  the  dis- 
ease is  not  much  more  prevalent  in  this  locality  than  it  is. 

The  changes  which  take  place  in  the  mucous  membrane  are  the 
same  as  when  the  disease  is  located  in  the  skin. 

The  lupus  nodules,  as  found  in  the  mucous  membrane,  are  minute 
white  points,  set  in  the  livid  red  and  slightly  thickened  membrane; 
they  may  assume  the  form  of  a  papillary  outgrowth  or  a  granulating 
patch,  which  may  ulcerate  and  cicatrize.  Ulceration  is  an  earlier  and 
more  frequent  symptom  in  tuberculosis  of  the  oral  cavity  than  in  other 
locations,  on  account  of  the  constant  maceration  of  the  newly-formed 
abnormal  tissue  by  the  fluids  of  the  mouth.  The  ulcerating  patch  has 
well-defined  borders,  and  is  usually  covered  by  a  whitish  film  or  false 
membrane,  produced  by  the  death  of  the  superficial  layers  of  the  mu- 
cous membrane.  On  removal  of  this  pseudo-membrane  the  character- 
istic granulating  surface  is  exposed.  Caseation  is  seldom  seen.  Ul- 
ceration and  cicatrization  sometimes  cause  serious  deformities  which 
interfere  with  the  proper  function  of  the  parts. 

The  most  characteristic  feature  of  tubercular  ulcer  of  the  mucous 
membrane  of  the  mouth  and  the  tongue  is  the  presence  of  minute 
tubercular  nodules  in  the  margins  and  underneath  the  layer  of  granula- 
tions, and  if  the  infection  has  extended  to  some  distance,  in  the  sur- 
rounding mucous  membrane  also.  (Senn.) 

The  disease  is  most  often  seen  in  persons  from  forty  to  fifty  years 
of  age,  and  rarely  attacks  the  very  young. 

Tuberculosis  of  the  Tongue  and  Pharynx  may  be  seen  inde- 
pendently of  the  disease  in  the  skin,  and  may  be  primary  or  secondary 
in  its  origin. 

Tubercular  ulcers  of  the  tongue  are  exceedingly  rare.  Butlin 
says  the  disease  is  so  uncommon  that  at  intervals  it  excites  an  entirely 
new  interest,  and  is  described  almost  as  if  it  were  a  new  disorder. 
These  ulcers  are  most  often  situated  upon  or  near  the  tip  of  the  tongue, 
though  they  are  found  in  all  locations,  especially  upon  the  dorsum. 
Men  are  more  prone  to  the  disease  than  women,  and  adults  more  than 
children.  The  ulcer  (or  ulcers,  for  there  may  be  more  than  one)  is  at 
first  indolent,  not  painful  or  very  tender,  but  later,  as  the  disease  takes 
on  a  more  active  progression,  it  becomes  more  and  more  painful,  ex- 


SURGICAL   TUBERCULOSIS. 


337 


cceding-ly  sensitive,  and  salivation  becomes  a  marked  symptom.  Fig. 
128  represents  a  typical  tubercular  ulceration  of  the  tongue.  In 
some  cases  the  tongue  is  rapidly  destroyed,  the  lymphatic  glands  be- 
coming infected,  and  as  the  sore  extends  the  strength  of  the  patient 
fails,  death  resulting  in  a  few  months,  or  at  the  end  of  a  year  or  two. 
Fig.  129  shows  a  tubercular  nodule  from  the  same  case  with  giant  cells 
and  beginning  caseation. 

Fig.  128. 


Giant  cell. 


Giant  cell. 


Round-celled 
infiltration. 


Tuberculous  Ulcer  of  the  Tongue.    X  50- 

Tubercular  disease  of  the  pharynx  may  extend  to  the  tonsils  and 
velum  palati,  destroying  these  organs,  or  if  cicatrization  takes  place 
the  posterior  nares  may  become  more  or  less  contracted,  and  the  exer- 
cise of  function  become  greatly  hindered,  speech  also  being  rendered 
imperfect.  The  larynx  may  also  become  involved  from  extension  of 
the  disease,  and  aphonia  result  from  implication  of  the  epiglottis  and 
the  vocal  cords. 

Differential  Diagnosis. — In  the  diagnosis  of  lupus  of  the  face  and 
mucous  membrane,  it  must  be  borne  in  mind  that  the  clinical  features 

23 


338 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


of  certain  forms  of  tertiary  syphilis  and  epithelioma  closely  simulate 
those  of  tuberculosis  of  the  skin  and  mucous  membrane,  and  to  dififer- 
-entiate  them  is  sometimes  very  difficult  or  well-nigh  impossible.  Even 
the  microscope  in  the  hands  of  an  expert  cannot  always  be  relied  upon 
as  an  exclusive  means  of  diagnosis,  on  account  of  the  great  similarity 
in  the  histologic  elements  of  a  tubercular  nodule  and  a  gumma. 

Fig.  129. 


Early  tubercle 
beginning 
caseation. 


Giant  cell. 


Tuberculosis  of  Tongue,  showing  Giant  Cells  and  Caseation.     X  50. 


A  careful  examination  into  the  history  of  the  case  is  of  the  greatest 
importance  when  trying  to  differentiate  between  tuberculosis  and  syph- 
ilis, for  even  though  the  patient  may  be  sure  that  syphilis  has  not  been 
acquired,  still  it  is  possible  that  the  disease  may  have  been  inherited; 
while  on  the  other  hand,  although  a  positive  history  of  primary  and 
secondary  syphilis  may  have  been  established,  it  is  not  improbable  that 
the  manifestations  may  be  those  of  tuberculosis. 

When  doubt  exists  as  to  the  true  nature  of  the  disease,  the  matter 
may  be  cleared  up  in  the  course  of  a  month  or  six  weeks  by  prescrib- 


SURGICAL  TUBERCULOSIS.  339 

ing  antisyphilitic  treatment,  and  at  the  same  time  inoculating  several 
guinea-pigs  or  rabbits,  after  the  method  of  Koch,  by  implanting  sub- 
cutaneously  small  fragments  from  the  diseased  area,  as  these  animals 
are  very  susceptible  to  tuberculosis. 

The  doubt  is  removed  either  by  the  improvement  manifest  in  the 
ulceration,  after  two  or  three  weeks,  as  a  result  of  the  antisyphilitic 
treatment,  or  by  the  production  of  tuberculosis  in  the  inoculated  ani- 
mals, and  their  death  at  the  end  of  five  or  six  weeks.  If  the  fragments 
which  have  been  implanted  are  from  syphilitic  ulcers,  it  will  have  no 
efifect  upon  these  animals,  as  they  cannot  be  inoculated  with  syphilis. 
In  differentiating  between  tuberculosis  and  epithelioma,  the  micro- 
scope is  the  only  reliable  means  of  diagnosis.  A  section  of  a  tubercular 
nodule  shows  a  fine,  delicate  reticulum,  the  meshes  of  which  are  occu- 
pied by  granulation-cells;  in  epithelioma  there  is  a  well-marked  retic- 
ulum, the  areolar  spaces  of  which  are  filled  with  embryonal  epithelial 
cells,  arranged  concentrically.  Blood-vessels  are  also  abundant  in 
epithelioma,  and  absent  in  the  tubercle  nodule. 

Glandular  infection  is  an  early  manifestation  in  epithelioma,  while 
in  tubercular  ulcerations  of  the  mucous  membrane  it  is  a  late  manifes- 
tation or  may  not  occur  at  all. 

Simple  ulcers  of  the  cheek  and  tongue  sometimes  occur  from  the 
mechanical  irritation  of  a  sharp  or  jagged  tooth,  resulting  from  a  cari- 
ous cavity,  or  from  masses  of  salivary  calculus,  or  from  a  misplaced 
tooth.  Such  ulcerations  are  easily  recognized  from  their  location  and 
appearance,  and  only  a  careless  observer  would  be  misled.  It  should 
be  borne  in  mind,  however,  that  they  may  become  the  focus  of  infec- 
tion of  tuberculosis,  or  the  starting-point  of  a  carcinomatous  growth. 

Prognosis. — Although  lupus  is  usually  confined  to  the  skin,  it 
may  attack  deeper  parts,  involving  the  muscles  and  periosteum,  caus- 
ing necrosis  of  the  bone.  Primary  tuberculosis  of  the  skin  may  lead  to 
infection  of  the  lymphatic  glands  nearest  to  the  seat  of  the  disease,  and 
eventually  to  general  miliary  tuberculosis.  Pulmonary  tuberculosis 
often  develops  as  a  secondary  complication.  It  occasionally  happens 
that  a  lupus  patch  is  the  cause  which  locates  the  formation  of  a  carci- 
noma. The  tendency  to  local  extension  varies  greatly.  In  some  cases 
the  disease  may  begin  in  early  life,  remain  stationary  for  a  number  of 
years,  then  suddenly  become  very  active  and  not  confined  to  the  skin, 
but  attacking  the  deeper  tissues  and  destroying  them  with  the  greatest 
rapidity,  regardless  of  their  structure.  In  tuberculosis  of  the  face,  the 
tendency  is  toward  rapid  extension;  in  some  cases  the  soft  tissues  and 
the  superficial  bones  may  be  completely  destroyed  in  a  few  months. 
On  the  other  hand,  the  process  of  repair  by  cicatrization  follows  closely 
upon  the  destruction  of  tissue,  and  extensive  scars  are  formed,  causing 
frightful  deformitv- 


340  SURGERY    OF    THE    FACE,    MOUTH,  AND    JAWS. 

The  prognosis,  so  far  as  the  hfe  of  the  patient  is  concerned,  is  fav- 
orable so  long  as  the  disease  remains  local,  or  does  not  progress  more 
rapidly  than  the  process  of  repair.  Regional  infection  of  the  lym- 
phatic glands  is  always  considered  as  a  menace  to  life,  as  sooner  or 
later  important  internal  organs  are  affected,  or  miliary  tuberculosis  be- 
comes general.  A  spontaneoris  cure  is  sometimes  effected.  The  dis- 
ease, however,  is  prone  to  recurrence  in  the  scar  tissue. 

The  prognosis  of  tubercular  ulceration  of  the  mucous  membrane 
of  the  mouth  is  usually  favorable,  except  when  located  in  the  tongue. 
When  associated  with  generalized  tuberculosis,  or  cachexia,  as  occas- 
ionally happens,  the  prognosis  is  exceedingly  unfavorable.  The  de- 
struction of  the  membrane  is  sometimes  very  extensive,  and  the  result- 
ing cicatrix,  by  its  contraction  and  adhesions,  causes  unsightly  de- 
formity, often  greatly  interfering  with  the  function  of  the  parts. 

The  prognosis  of  tubercular  ulcer  of  the  tongue  is  almost  as  bad 
as  in  carcinoma.  The  disease  is  not  only  fatal,  but  the  lease  of  life  is 
usually  short,  the  end  coming  in  a  few  months,  or  in  a  year  or  two  at 
the  longest.  The  pain  and  distress  which  accompany  the  downward 
course  of  the  disease  is  very  great,  while  the  patient  is  considered  as 
fortunate  if  the  end  is  hastened  by  the  presence  of  a  rapidly-progressive 
tuberculosis  of  some  important  internal  organ,  which  produces  a  fatal 
termination  before  the  ulcer  of  the  tongue  becomes  large  and  painful. 
Occasionally  tubercular  ulcers  of  the  tongue  heal,  but  the  cure  is  usu- 
ally only  a  temporary  affair,  for  sooner  or  later  the  disease  returns,  the 
second  outbreak  being  more  rapid  in  its  course,  and  all  efforts  for  its 
cure  are  unavailing.     (Butlin.) 

Treatment.— The  internal  treatment  of  tubercular  disease  of  the 
skin  and  the  mucous  membrane  should  be  governed  by  the  indications 
of  the  patient.  There  is  no  known  remedy  that  has  any  specific  action 
in  curing  the  disease,  or,  according  to  Hyde,  that  is  capable  of  reliev- 
ing the  victim  of  his  local  ailment.  Recent  authors  think  the  only 
remedy  that  deserves  any  confidence  is  arsenic,  in  the  form  of  Fowler's 
solution.  It  is  administered  in  doses  of  from  three  to  ten  drops  after 
meals,  diluted  with  water,  beginning  with  the  smallest  dose  and  grad- 
ually increasing  until  the  maxinnmi  dose  is  reached  or  the  physiologic 
effect  is  produced,  and  then  gradually  diminishing.  To  be  of  any  real 
value  its  use  must  be  continued  for  several  weeks  or  months. 

Cod-liver  oil,  the  tincture  of  chlorid  of  iron,  the  bitter  tonics,  com- 
bined with  nutritious  diet,  out-door  exercise  and  sea-bathing,  are  the 
most  useful  agents  in  sustaining  the  general  health,  assisting  nature  to 
limit  the  spread  of  the  disease  and  favor  the  process  of  repair. 

The  local  treatment  consists  of  the  removal  of  the  diseased  tissue 
by  surgical  operation,  under  anesthetics;  to  be  efficient  it  must  be 
thorough;  half-way  measures  are  of  no  more  real  value  here  than  they 


SURGICAL  ti'1!i-:rculosis.  341 

would  be  in  the  treatment  of  malignant  neoplasms,  for  the  disease  is 
almost  sure  to  recur  unless  every  particle  of  infected  tissue  is  removed. 

The  use  of  caustics  is  generally  of  no  real  value,  often  positively 
harmful. 

Since  the  nature  of  the  disease  has  been  recognized,  antiseptic 
agents  have  been  recommended  for  local  treatment.  White  uses  the 
bichlorid  of  mercury,  one  to  two  grains  to  an  ounce  of  water,  applied 
for  half  an  hour  morning  and  evening  on  compresses  kept  wet  with  this 
solution,  or  an  ointment  made  from  the  same  drug,  two  grains  to  the 
ounce,  applied  continuously,  and  changed  morning  and  evening.  Care 
must  be  taken  that  salivation  is  not  produced  by  absorption  of  the 
drug.  He  also  obtained  satisfactory  results  by  the  application  of  a  2 
to  4  per  cent,  solution  of  salicylic  acid  in  castor  oil.  Iodoform  in 
the  form  of  the  powder,  ointment,  or  emulsion  in  glycerol  is  recom- 
mended as  one  of  the  very  best  antiseptics  in  all  forms  of  tubercular 
disease. 

Balsam  of  Peru  is  also  of  benefit  as  a  local  application. 

Dr.  Thomas  S.  K.  Morton,  of  Philadelphia,  recommends  ace- 
tanilid  as  an  antiseptic  dressing  in  all  surgical  wounds,  tuberculous 
ulcerations,  and  bone-disease,  either  in  substance  or  as  gauze,  or  oint- 
ment (i  in  8),  or  dissolved  in  alcohol  or  oil  (as  an  injection).  A  10  per 
cent,  solution  in  water  seems  to  answer  every  purpose  in  preventing 
suppuration  in  all  surgical  cases,  while  it  seems  to  act  better  than  iodo- 
form in  the  treatment  of  tuberculous  lesions.  Care  must  be  exercised 
in  the  use  of  the  drug  in  substance  to  prevent  toxic  symptoms. 

Antiseptic  agents,  however,  can  never  become  efficient  means  of 
treatment  in  this  aflfection,  for  the  reason  that  they  cannot  be  brought 
into  direct  contact — except  at  the  surface  and  for  a  little  distance  be- 
neath— with  the  bacilli  and  those  parts  in  an  active  state  of  disease. 
In  those  cases  in  which  a  radical  operation  is  declined  by  the  patient 
or  friends,  the  above  treatment  is  the  next  best  means  at  the  disposal 
of  the  surgeon. 

Treatment  by  repeated  exposure  of  the  affected  tissue  to  the  in- 
fluence of  the  "Roentgen-ray"  has  been  advocated  during  the  last  three 
years  by  certain  German  and  Austrian  physicians  as  a  cure  for  this 
disease.  Most  of  the  work  in  this  line  has  been  done  by  Schiff  and 
Freund,  of  Vienna,  and  by  Kummell,  of  Hamburg.  A  few  cases  have 
been  reported  by  various  surgeons  of  Europe,  and  three  in  the  United 
States,  one  by  Jones,  of  San  Francisco,  one  by  Knox,  of  Cincinnati, 
and  one  by  Pusey,  of  Chicago.  The  technique  of  the  treatment  ad- 
vocated by  Schiff  and  Freund  is  that  of  repeated  exposures  to  a  weak 
light  of  definite  strength.  The  light  is  produced  by  a  secondary  cur- 
rent generated  in  an  induction  coil  of  30  cm.  spark-length,  which  in 
turn  is  energized  by  a  weak  primary  current  of  12  volts  and  i^  amperes, 


342  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

interrupted  from  800  to  looo  times  per  minute.  The  exposures  are 
continued  from  five  to  fifteen  minutes,  and  the  distance  of  the  tube 
from  the  surface  being  treated,  varies  from  15  to  5  cm.  The  surround- 
ing surfaces  should  be  protected  by  a  lead  mask.  Care  must  be  exer- 
cised not  to  overstep  the  bounds  of  safety  either  as  to  the  strength  of 
the  current,  the  length  of  time  of  the  exposure,  or  of  the  distance  at 
which  the  tube  is  held  from  the  surface.  The  object  is  to  obtain  by 
the  exposure  the  required  effects  of  the  ray  without  producing  injury 
to  the  tissues. 

Excision  is  the  most  eft'ectual  form  of  radical  treatment,  but  un- 
fortunately it  cannot  be  performed  in  all  cases. 

This  operation  is  not  admissible  when  the  disease  is  upon  the  nose 
or  some  other  prominent  part  of  the  face  where  the  resultant  deformity 
would  be  nearl}^  as  unwelcome  to  the  sufferer  as  the  disease,  nor  where 
the  disease  is  very  extensive. 

When  excision  is  practiced,  the  lines  of  incision  should  be  made  at 
some  distance  from  the  margins  of  the  visible  diseased  area,  in  order 
that  all  infected  tissue  may  be  included;  while  great  care  should  be  ex- 
ercised in  removing  the  deeper  portions  of  the  infiltration,  as  this  may 
send  out  projections  at  various  points,  which  must  be  extirpated  in 
order  to  insure  non-recurrence.  If  it  becomes  necessary  to  remove 
extensive  portions  of  the  skin,  the  gap  may  be  filled  by  the  Thiersch 
method  of  skin-grafting. 

Another  method  of  radical  operation  is  by  curetting.  This  opera- 
tion consists  of  scraping  out  the  diseased  tissue  by  means  of  sharp 
spoons  or  curettes.  Lupus  tissue  is  much  softer  than  the  healthy 
skin,  consequently  the  curette  easily  penetrates  the  former,  while  the 
latter  offers  sufiicient  resistance  to  guide  the  operator  in  removing  the 
diseased  tissue. 

Besnier  recommends  the  use  of  the  galvano-cautery  for  removing 
the  diseased  tissue,  and  he  has  devised  special  cautery  points  for  this 
purpose. 

The  writer  believes  the  most  effectual  plan  of  treatment  is  a  com- 
bination of  the  last  two  methods,  the  bulk  of  the  diseased  tissue  being 
first  removed  by  the  curette  and  then  followed  by  the  galvano-cautery. 
The  storage  battery  makes  it  possible  for  every  surgeon  to  use  Bes- 
nier's  cautery  point  and  knives.  No  more  successful  method  can  be 
used  to  follow  up  and  remove  the  more  minute  points  of  the  disease 
which  have  been  left  behind  by  the  other  operations  of  excision  and 
curetting. 

Antiseptic  after-treatment  is  very  desirable,  and  the  patient  should 
be  kept  under  observation  for  some  time  after  the  healing  of  the 
wound.  The  site  of  the  operation  should  be  protected  from  injury  for 
several  months,  as  a  precaution  against  the  pathogenic  action  of  re- 
maining latent  bacilli  or  reinfection  from  the  outside. 


SURGICAL   TUBERCULOSIS.  343 

The  treatment  of  the  disease  located  in  the  mucous  membrane  of 
the  mouth  should  be  upon  the  same  general  principles  as  when  located 
in  the  integument.  The  curette  and  galvano-cautery  are  most  appli- 
cable for  radical  treatment. 

Excision,  if  practiced  early,  is  the  most  effectual  treatment  in 
tubercular  ulceration  of  the  tongue.  This  may  be  accomplished  by 
removing  a  wedge-shaped  piece  with  the  knife,  and  stitching  the  sur- 
face together,  or  it  may  be  removed  with  the  ecraseur  or  the  galvano- 
cautery.  Methods  of  operating  will  be  found  described  in  the  chapter 
which  deals  with  carcinoma  of  the  tongue.  Recurrence,  however,  is 
the  rule  after  operations  for  this  disease  when  located  in  the  tongue. 


CHAPTER    XXXV. 
ACTINOMYCOSIS  HOMINIS. 

Definition. — Actinomycosis  (from  the  Greek  uktIv^  a  ray;  iJ.vK-q<;^ 
a  fungus).  A  specific,  infectious,  inoculable  disease  affecting  both  man 
and  the  lower  animals.  The  disease  was  first  observed  in  cattle  and 
has  been  variously  known  as  "^clyers,"  "lumpy  jaw,"  and  "holdfast." 
It  is  caused  by  a  parasitic  organism  known  as  the  streptothrix  actino- 
mycotica,  actinocladothrix,  actinomycosis  hovis,  or  the  ray  fungus, 
more  correctly  the  ray  bacterium.  This  organism  causes  lesions  that 
are  somewhat  similar  to  those  produced  by  the  bacillus  tuberculosis  and 
it  has  therefore  been  classed  with  the  infective  granulomata. 

History. — Until  a  comparatively  recent  date  very  little  of  a  definite 
nature  has  been  known  in  reference  to  the  cause  or  the  pathology  of 
the  disease.  The  disease  was  undoubtedly  seen  by  many  early  writers 
and  described  either  as  tuberculosis  or  cancerous  growths. 

The  first  reference  to  the  disease  to  be  found  in  medical  literature 
occurred  in  the  Journal  de  Medecine  Veterinaire  in  an  article  written 
by  Leblanc  (1826).  This  article  described  the  disease  as  appearing  in 
cattle,  the  most  prominent  symptoms  being  swelling  and  suppuration 
of  the  jaw. 

Prof.  Dick  (1833)  described  the  disease  as  an  affection  of  cattle 
manifested  in  swelling  of  the  jaw  and  known  as  "clyers."  In  1841,  he 
called  attention  to  the  fact  that  the  disease  was  known  to  affect  human 
beings,  the  seat  of  the  affection  being  in  the  jaw. 

Prof.  Simmonds  (1845)  referred  to  the  disease  as  found  in  the 
tongue,  as  "scirrhus  tongue." 

Langenbeck  (1845)  described  a  case  of  the  disease  occurring  in  the 
vertebra  of  a  young  man  the  discharges  from  which  contained  yellow 
granules,  as  "vertebral  caries  with  yellow  grains  in  the  pus." 

Duvaine  (1850)  mentions  a  case  of  tumor  occurring  in  the  jaw 
of  an  ox,  in  which  there  were  discovered  yellow  grains  in  the  pus, 
"which,  under  the  microscope,  had  neither  the  characteristics  of  tuber- 
cle nor  of  pus." 

Lebert  (1858)  published  a  case  of  the  disease  occurring  in  man, 
which  he  had  seen  in  the  practice  of  Louis  in  1848.  In  this  case  the 
patient  was  suffering  from  an  abscess  in  the  thoracic  region  accom- 
344 


ACTINOMYCOSIS    IIOMINIS.  345 

panied  with  great  swellini^.  Later  he  described  very  minutely  the 
actinomvcotic  granules,  and  speaks  of  special  bodies  found  in  the  pus. 
Robin  and  Laboulbene  ( 1853 )  called  attention  to  the  disease  in  a 
memoire  upon  the  peculiar  character  of  the  disease,  presented  to  the 
French  Societe  de  Biologic. 

Rivolta  (1863)  spent  many  years  in  studying  the  disease  as  found 
in  the  jaws  of  oxen.  These  tumors  are  known  in  Italy  as  the  "mal  de 
rospo.''  In  1868  he  published  the  results  of  his  researches  into  the  ac- 
tive causes  of  the  disease,  and  announced  the  discovery  of  certain  rod- 
shaped  bodies  in  the  pus,  which  he  compared  to  the  rods  of  the  retina. 
These  after  several  failures  he  succeeded  in  inoculating  into  other 
animals,  and  in  later  communications  he  established  the  identity  of  the 
disease  as  it  appears  in  the  horse,  the  dog,  and  several  of  the  domes- 
ticated animals. 

Perroncito  (1875)  discovered  sulfur-like  granules  in  a  case  of 
osteosarcoma  (supposedly)  in  the  jaw  of  an  ox. 

Bollinger  (1877)  published  an  elaborate  article  upon  the  disease 
as  found  in  cattle.  This  was  the  first  article  published  which  gave  a 
minute  description  of  the  pathology  of  the  disease  as  it  appeared 
macroscopically  and  microscopically.  He  says,  in  describing  the  dis- 
ease and  its  location:  "On  the  lower  jaw  of  cattle  tumor-like 
neoplasms  sometimes  occur,  which  proceed  from  the  alveoli  of  the 
molars  or  from  the  spongiosa  of  the  bone,  inflate  the  latter,  corrode  it, 
and  finally,  after  having  loosened  the  molars  and  destroyed  the  normal 
tissues  which  impeded  their  growth,  break  through  the  skin  externally 
or  into  the  oral  or  pharyngeal  cavities. 

"The  inflated  bones  have  a  pumice-stone-like  appearance,  caused 
by  central  osteoporosis  and  external  hyperostosis.  Most  of  the  bulbous 
and  conglomerated  growths,  which,  after  some  length  of  time,  often 
become  puriform  or  entirely  break  down  and  lead  to  the  formation  of 
ulcers,  abscesses,  and  fistulous  canals,  usually  attain  the  size  of  a  child's 
bead  or  even  larger. 

''Such  tumors  are  composed  of  a  conglomeration  of  soft  con- 
sistence, pale  yellowish  color,  and  juicy  luster,  united  by  tense  connec- 
tive tissue.  On  the  surface  of  the  cut  we  find  scattered,  usually  cloudy, 
yellowish-white,  abscess-like  centers,  or  the  hard  cores  are  of  spongious 
structure,  showing  numerous  hempseed-sized  spaces  and  caverns  in 
the  fibrous  stroma,  which  contain  murky,  yellow,  thick,  often  cheesy 
pap.  The  mass  of  the  tumor  is  infiltrated  with  a  puriform  or  cheesy 
substance  which  often  shows  a  reticular  arrangement,  and  may  be 
readily  obtained  by  scraping  the  surface  of  the  cut  with  a  knife. 

"The  microscopical  examination  reveals,  among  other  things, 
numerous  opaque,  slightly  yellow,  coarsely  granulated  or  gland-like 
bodies  of  dififerent  sizes,  often  resembling  mulberries.    These  are  here 


346  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

and  there  incrusted  with  Hme,  and  on  closer  examination  are  found  to 
be  of  a  fungous  nature.  This  mycosis  occurs  not  only  in  the  jaw- 
bones, but  also  in  the  tongue  of  cattle,  where  it  leads  to  the  formation 
of  erosions,  ulcers,  and  scars,  or  to  secondary  interstitial  glossitis."* 
Bollinger  submitted  these  yellow  granules  to  the  botanist  Harz,  of 
Munich,  who  discovered  their  parasitic  nature  and  gave  them  their 
name  Actinomycosis. 

Israel  (1878)  published  the  results  of  his  observations  and  inves- 
tigations concerning  two  cases  of  the  disease  occurring  in  human  beings 
which  presented  the  symptoms  of  chronic  pyemia.  Abscesses  appeared 
in  great  numbers  upon  all  parts  of  the  body,  and  when  opened  dis- 
charged a  profuse  malodorous  pus,  strewn  with  yellowish  millet-seed- 
like granules.  These  granules  when  crushed  revealed  certain  mor- 
phologic elements  which  were  afterward  recognized  and  proved  to  be 
the  elements  of  the  ray-fungus.    Israel  reported  a  third  case  in  1879. 

Ponfick  (1879)  found  the  same  fungus  in  a  prevertebral  abscess 
in  man,  and  was  the  first  (1882)  to  suggest  the  identity  of  the  disease 
as  found  in  man  and  the  lower  animals. 

Johne  was  really  the  first  to  establish  the  inoculability  of  the  dis- 
ease by  introducing  the  yellow  granules  into  an  ox.  Previous  to  this 
Bollinger  and  Rivolta  had  failed  to  reproduce  the  disease  by  inoculation. 

Harley  (1884),  of  St.  Thomas  Hospital,  London,  reported  the  first 
case  of  actinomycosis  in  man  that  had  been  recognized  in  England. 
Bristow  reported  a  case  in  the  same  year.  Several  specimens  of  "scrof- 
ulous disease"  to  be  seen  in  St.  Thomas  Hospital  Museum,  which  have 
been  there  for  many  years,  were  in  1884  studied  microscopically,  with 
the  view  of  ascertaining  their  real  nature,  and  were  found  to  be  cases 
of  actinomycosis. 

James  Israel  (1885)  in  his  classic  article  t  gathered  and  classified 
all  the  cases  on  record  at  this  time  in  reference  to  the  point  of  entrance 
of  the  infection,  which  he  was  able  to  group  under  four  general  heads : 

I.  Cases  which  gained  an  entrance  through  the  oral  and  pharyn- 
geal cavities. 

(a)      Central  formation  of  foci  in  the  mandibula. 
{h)     Localization  on  the  margin  of  the  lower  jaw  in  the  sub- 
maxillary and  sublingual  regions. 
{c)     Localization  on  the  neck. 

{d)     Localization  on  the  periosteum  of  the  upper  jaw. 
{e)     Localization  in  the  region  of  the  cheek. 

II.  Cases  of  primary  actinomycosis  of  the  respiratory  tract. 

III.  Cases  of  primary  actinomycosis  of  the  intestinal  tract. 

IV.  Cases  with  uncertain  point  of  entrance. 

*Miller's  "Micro-organisms  of  the  Mouth,"  1890. 
tKlinische  Beitrage  ziir  Aktinomykose  des  Menschen. 


ACTINOMYCOSIS    IIOMINIS.  347 

Belfield  (1883)  published  the  first  paper  upon  the  disease  in 
America,  as  observed  in  cattle.  This  article  briefly  reviews  certain  cases 
found  in  cattle  at  the  Chicago  Stock-yards.  In  three  of  the  cases  the 
tumors  were  located  in  the  upper  jaw,  a  fourth  was  located  in  the  lower 
jaw,  and  the  fifth  below  the  orbit.  The  microscopic  examination  showed 
radiating  fungi.  The  disease,  however,  seems  to  have  been  recognized 
before  this  time  by  Osier  and  Clement  as  occurring  in  Canadian  cattle. 
Law  also  demonstrated  the  nature  of  the  disease  to  his  classes  in 
Cornell  University,  and  Taylor  of  the  Agricultural  Department  in 
Washington  demonstrated  it  in  dogs. 

Murphy  (1885),  however,  was  the  first  to  demonstrate  the  disease 
as  occurring  in  man  in  the  United  States.  In  a  paper  read  before  the 
Cook  County  Medical  Society,  Chicago,  be  describes  the  case  as  oc- 
curring in  a  female  servant,  aged  twenty-eight  years.  The  disease  be- 
gan in  a  left  lower  tooth  in  the  form  of  "toothache"  accompanied  with 
swelling  of  the  throat  and  great  pain  in  swallowing  (dento-alveolar 
abscess  in  all  probability).  After  using  poultices  for  several  days  the 
swelling  disappeared,  to  return  a  few  days  later.  An  abscess  formed 
and  was  lanced,  discharging  a  large  quantity  of  pus.  From  this  she 
rapidly  recovered,  but  in  a  week  another  swelling  formed  below  the 
angle  of  the  jaw,  in  the  tissues  of  the  neck.  This  was  the  size  of  a 
walnut,  and  the  tissues  about  it  were  indurated.  There  was  fluctuation, 
but  only  a  little  pus.  A  drainage-tube  was  inserted,  through  which 
pus  containing  sulfur  granules  escaped.  The  mass  was  removed, 
the  tooth  extracted,  and  the  site  of  the  tumor  and  the  cavity  curetted. 
Primary  union  resulted. 

Ochsner  and  Schirmer  (1886)  each  reported  a  case  occurring  in 
man.  Many  cases  have  since  this  time  been  reported  in  medical  litera- 
ture, both  home  and  foreign. 

Ruhrah  (1899)  in  an  elaborate  article*  has  gathered  all  of  the  cases 
published  in  American  medical  literature  and  several  unpublished  cases 
the  notes  of  which  were  furnished  him  by  the  operators,  making  65  in 
all.  The  writings  upon  actinomycosis  (as  found  in  man  and  the  lower 
animals)  are  now  very  voluminous  in  both  European  and  American 
medical  literature. 

Etiology. — Actinomycosis  is  caused  by  the  entrance  into  the  tis- 
sues of  the  Streptothrix  actinomycotica,  a  cryptogam  which  is  found 
upon  grain,  grass,  straw,  or  seeds.  The  Ray-fungus  or  actinomyces 
microscopically  is  composed  of  three  distinguishing  morphologic  ele- 
ments, viz :  club-shaped  formations ;  a  centrally-placed  network  of 
fungous  filaments  of  varying  shape  and  size,  and  fine  coccus-like  bodies. 

The  fungous  threads  or  filaments  radiate  from  the  center.     The 


*Annals  of  Surgery,  1899. 


348 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


threads  are  sometimes  club-shaped  at  their  extremities,  but  more  often 
this  feature  is  absent  in  man.  The  most  constant  and  characteristic 
morphologic  elements  are  the.  coccus-like  bodies.  Sometimes  one  of 
these  filaments  having  club-shaped  extremities  will  extend  far  beyond 
the  others,  as  shown  in  Fig.  130. 

The  ray-fungus  as  it  appears  in  man  is  a  small  globular  mass, 
usually  described  as  about  the  size  of  a  millet-seed,  commonly  of  a 
pale  yellow  color,  though  sometimes  brown  or  green.     The  presence 

Fig.  130. 


The  Ray-Fungus.    (Actinomyces.)    (After  Ponfick.) 


of  these  bodies  in  the  discharges  of  chronic  inflammatory  swellings  is 
pathognomonic  of  this  disease.  It  may  gain  access  to  any  part  of  the 
body,  through  a  wound  or  an  abrasion.  The  usual  locations  of  the  in- 
fection are  the  skin,  the  mucous  membrane  of  the  mouth,  the  alimentary 
tract,  and  the  respiratory  apparatus.  A  carious  tooth,  an  alveolar  ab- 
scess, the  open  alveolus  of  a  recently  extracted  tooth,  an  inflamed  and 
ulcerating  gum,  or  an  abrasion  of  the  mucous  membrane,  furnish  the  most 
inviting  avenues  of  infection,  for  the  reason  that  they  present  an  open 


ACTINOMYCOSIS    HOMINIS.  349 

atrium;  and  are  the  tissues  with  which  the  organism  comes  most  often 
in  contact.  The  organism  may  also  gain  an  entrance  to  the  body 
through  the  inspired  air  and  the  drinking-water. 

Farmers,  liostlers,  threshers,  and  millers  should  therefore  be  cau- 
tioned against  chewing  straws  or  eating  raw  grain,  as  the  organism 
is  found  in  its  primitive  state  growing  upon  these  substances. 

Sex. — In  the  first  fifty-six  cases  reported  as  occurring  in  America, 
38  were  males,  15  were  females,  and  in  3  the  sex  was  not  stated.  Out 
of  357  cases  reported  by  Poncet  and  Berard  248  were  males  and  109 
females.    Leith  found  295  males  and  1 10  females  in  a  total  of  405  cases. 

Age. — There  seems  to  be  no  period  in  life  when  the  individual  is 
not  liable  to  contract  the  disease.  In  the  American  cases  the  youngest 
was  six  years  of  age  and  the  eldest  sixty-five.  The  earliest  age  at  which 
the  disease  has  been  seen  was  in  a  child  of  one  year,  and  the  oldest  in 
an  individual  of  seventy-seven  years  of  age.  According  to  Hutyra's 
table,  which  was  arranged  by  decades,  it  would  seem  that  the  disease 
was  most  prevalent  in  early  adult  life.  This,  however,  may  be  ac- 
counted for  by  the  fact  that  the  exposure  to  the  disease  is  greater  at 
this  period  than  at  any  other.  Hutyra's  figures  are  as  follows :  From 
five  to  nine,  7;  ten  to  nineteen,  44;  twenty  to  twenty-nine,  118;  thirty 
to  thirty-nine,  78 ;  forty  to  forty-nine,  54 ;  over  fifty,  56. 

Race. — The  liability  to  the  disease  seems  to  be  about  the  same  in 
all  races.  The  negro  presents  no  especial  predisposition  to  the  disease 
over  the  white  race. 

Geographical  Distribution. — The  disease  seems  to  be  more  prev- 
alent in  the  north  and  south  temperate  zones  than  in  tropical  climates. 
The  disease  has  been  found  in  man  and  among  cattle  in  America, 
in  nearly  all  of  the  European  countries,  in  Australia  and  some  of  the 
islands,  and  in  Algeria  and  Egypt.  The  disease  is  more  prevalent 
among  those  living  in  the  country,  and  especially  more  frequent  in 
persons  who  are  in  contact  with  cattle  and  horses  and  who  handle  hay, 
straw,  and  grains.  It  has  been  stated  that  it  was  most  frequent  among 
cattle  which  grazed  upon  salt  marshes  that  were  from  time  to  time 
flooded  by  the  sea. 

Sources  of  Infection. — Authorities  do  not  agree  as  to  the  pos- 
sibility of  the  disease  being  directly  communicated  from  cattle  by  con- 
tagion. Leith  denies  this  possibility,  and  Liebman  has  shown  that  the 
organism  loses  its  virulence  in  passing  through  animals.  The  character 
of  the  organism  is  such  that  it  would  not  be  likely  to  be  readily  com- 
municated from  one  animal  to  another.  Ochsner,  however,  reports 
two  cases  which  point  very  strongly  to  direct  infection  from  animals 
to  man.  The  first  case  refers  to  a  man  who  had  driven  for  the  six 
months  previous  to  his  illness  a  horse  afifected  with  "lumpy  jaw"  ;  while 
in    the    second    case    the    patient    was    a    cattle-dealer    who    had    fre- 


350  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

quently  handled  cattle  affected  with  this  disease,  and  was  in  the  habit 
of  treating  the  diseased  animals  by  curetting  the  swelling  and  cauter- 
izing the  cavity  with  arsenical  paste.  Murphy  reports  a  case  which 
was  presumably  acquired  from  a  dog,  and  Ponfick  one  following  the 
bite  of  a  louse.  Baracz  has  reported  a  case  of  the  transmission  of  the 
disease  from  a  man  to  a  woman  by  kissing;  Two  other  similar  cases 
have  since  been  reported,  but  these  appear  to  be  the  only  cases  on  rec- 
ord in  which  the  disease  has  been  conveyed  directly  from  one  human 
being  to  another. 

It  has  been  stated  that  the  infection  might  occur  from  flesh  and 
milk  used  as  food.  There  are,  however,  no  authentic  cases  on  record 
of  the  disease  occurring  in  this  manner.  It  is  possible  for  the  infection 
to  result  from  breathing  dust  laden  with  the  micro-organisms  during 
the  threshing  of  grain,  provided  an  open  atrium  exists  in  some  part  of 
the  respiratory  tract. 

The  disease  is,  however,  most  often  transmitted  by  direct  infection 
from  the  plant  or  grain,  by  the  introduction  of  the  sharp  barbs  or 
beards  of  the  grain  or  leaves  of  the  plant.  In  numerous  cases  the 
barbs  of  the  grain  have  been  found  in  the  infected  tissue.  Johne  first 
observed  this  fact  when  he  found  a  barb  of  grain  in  the  tonsil  of  a 
pig  which  died  from  the  disease.  Bostrom,  however,  established  the 
relationship  between  the  fragments  of  the  grain  and  the  plant,  as  he 
found  the  barbs  of  the  grain  imbedded  in  the  infected  tissues  of  eleven 
cases.  Several  other  cases  are  on  record  in  which  the  presumptive 
evidence  is  strong  that  the  disease  was  contracted  in  this  manner,  as 
some  were  habitual  users  of  straws  as  toothpicks  or  were  accustomed 
to  chewing  raw  grains. 

Location  of  the  Disease. — The  location  of  the  disease  as  found  in 
cattle,  according  to  Poncet  and  Berard,  who  gathered  the  statistics  of 
various  observers,  is  as  follows:  Claus,  of  Bavaria;  Jaw,  51  per  cent.; 
tongue,  29  per  cent. ;  lung,  2  per  cent. ;  skin,  o  per  cent.  Mari,  of  Rus- 
sia; Jaw,  32.8  per  cent.;  tongue,  i  per  cent,;  lung,  5.6  per  cent.;  skin, 
51  per  cent.;  submaxillary  and  bronchial  glands,  11  per  cent.  Leclerc, 
of  France;  Jaw,  72  per  cent.;  tongue,  18  per  cent.;  lung,  9  per  cent.; 
skin,  o  per  cent. 

Moosbrugger  (1887)  published  a  collection  of  statistics,  for  man, 
of  the  disease  in  Germany  which  covered  the  reports  of  73  observers, 
giving:  Head,  neck,  lower  jaw,  mouth,  and  throat,  29;  upper  jaw 
and  cheek,  9;  tongue,  i;  digestive  tract,  esophagus,  2;  intestines,  ii; 
bronchi  and  lungs,  14;  doubtful,  7. 

Leith's  statistics  give  the  anatomical  distribution  of  393  cases  as 
follows:  Head  and  neck,  207;  tongue,  13;  pulmonary,  52;  abdomen, 
88;  skin,  10;  doubtful,  23. 

Illich's  figures  place  the  number  of  cases  in  which  the  disease  was 


ACTINOMYCOSIS    IIOMINIS.  351 

found  in  the  head  and  neck  as  234  in  a  total  number  of  421  cases,  or 
55  per  cent. 

Sokolow  found  in  a  total  number  of  62  cases  that  the  disease  was 
located  in  the  head  and  neck  33  times,  or  53  per  cent. 

Guder  out  of  20  cases  in  man  found  it  located  in  the  face  and  neck 
II  times,  or  50.5  per  cent. 

Poncet  and  Berard  collected  the  histories  of  67  cases  in  man,  and 
found  it  present  in  the  face  and  neck  54  times,  or  82  per  cent. 

Rutimeyer  states  the  disease  occurs  in  the  jaw  in  50  per  cent,  of  the 
cases.  In  58  of  the  cases  reported  as  occurring  in  America  it  was 
located  in  the  lower  jaw,  mouth,  and  throat  19  times,  and  in  the  upper 
jaw  and  cheek  8  times ;  total  for  the  head  and  neck,  27,  or  46.5  per  cent. 

Ruhrah,  who  had  gathered  the  histories  of  1094  cases,  reported 
from  various  sources,  found  that  it  occurred  in  the  head  and  neck  604 
times,  or  in  56  per  cent,  of  the  cases.  After  eliminating  the  cases  that 
might  have  been  counted  twice,  be  found  that  it  occurred  in  the  head 
and  neck  359  times,  or  55  per  cent. 

Secondary  Infection. — Extension  of  the  disease  to  remote  parts  of 
the  body  is  always  by  the  blood-current  and  never  by  the  lymphatics 
and  glands.  Murphy  says:  Extension  of  the  disease  takes  place  in 
two  ways :  "First,  by  diffusion  in  loco,  and  second,  by  the  entrance  of 
the  actinomyces  into  the  blood-stream.  This  extension  is  greatest  in 
the  direction  opposite  to  the  course  of  the  lymphatics."  The  organisms 
which  gain  access  to  the  blood-stream  are  floated  along  in  the  current 
until  they  meet  some  obstruction,  where  they  become  lodged,  multiply, 
and  form  secondary  foci  of  the  disease. 

Secondary  infection  of  internal  organs  may  also  take  place  from 
'  primary  foci  of  infection  located  in  the  mouth  and  jaws,  through 
swallowing  or  inspiring  the  germs  of  the  disease.  An  interesting  case 
of  this  character  has  been  published  by  Israel.  The  patient  was  a  driver, 
twenty-three  years  of  age,  who  was  in  the  habit  of  sleeping  upon  the 
straw  or  in  the  haymow,  and  often  drank  out  of  the  same  trough  with 
His  horses.  Israel  found  the  ray-fungus  in  the  secretions  of  the 
abscesses  and  ulcers  which  covered  the  left  side  of  the  man's  breast, 
but  was  not  able  to  discover  the  primary  seat  of  the  infection  until 
after  the  patient's  death.  The  autopsy  revealed  an  actinomycotic 
cavern  in  the  anterior  portion  of  the  superior  lobe  of  the  left  lung ;  from 
here  it  extended  upon  the  peripheral  tissue  and  had  broken  through 
the  wall  of  the  chest  in  various  places. 

In  this  cavern  Israel  found  an  irregular  calcareous  body  about  the 
size  of  a  No.  6  shot,  which  upon  examination  was  found  to  consist  of 
a  small  fragment  of  dentin,  surrounded  by  a  chalky  mass  composed  of 
phosphate  and  carbonate  of  lime.  Microscopic  preparations  from  this 
revealed,  besides   the   dentin,   numerous   threads   of   ray-fungus,   and 


352  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

there  was  no  doubt  that  the  fragment  of  dentin  was  the  carrier  of  the 
infection.  Another  case  of  primary  infection  of  the  lung  from  the 
inspiration  of  the  fungus  has  been  reported  by  Baumgarten.  In  this 
case  the  infection  was  caused  by  the  inspiration  of  the  specific  fungal 
elements  which  had  accumulated  in  the  left  tonsil.  Miller  found  that 
out  of  113  cases  of  actinomycosis  hominis,  the  histories  of  which  he  had 
carefully  examined,  33  were  produced  by  invasion  of  the  ray-fungus 
through  the  oral  and  pharyngeal  cavities. 

Incubation  Period. — The  disease  has  no  definite  period  of  incuba- 
tion, as  the  cases  in  which  the  histories  were  definitely  known  vary 
considerably  in  the  periods  at  which  the  disease  was  developed  after 
infection.  These  periods  range  from  a  few  weeks  to  several  months. 
The  progress  of  the  disease  after  infection  has  been  established  is  also 
very  slow,  giving  a  chronic  character  to  the  disease. 

Pathology. — The  general  characteristics  of  the  disease  are  those 
of  chronic  inflammation,  the  lesions  produced  by  the  organism  being 
somewhat  similar  to  those  caused  by  the  action  of  the  bacillus  tuber- 
culosis, and  it  is  therefore  classed  with  the  infective  granulomata. 
The  pathogenic  action  of  actinomyces  upon  the  tissues  is  to  transform 
mature  connective  tissue  into  embryonal  or  granulation  tissue.  The 
organism  does  not  possess  pyogenic  functions,  consequently  the  pres- 
ence of  pus  in  actinomycosis  is  the  result  of  infection  with  the  p3^ogenic 
organisms. 

According  to  Ruhrah  the  action  of  the  actinomyces  upon  the  tis- 
sues is  as  follows :  "The  organism,  having  found  a  lodgment,  grows 
in  colonies.  At  first  there  is  a  poisoning  of  the  cells  in  the  immediate 
neighborhood.  This  leads  to  hyaline  degeneration  of  the  cells,  then  to 
necrosis.  This  area  is  invaded  by  small  round  mononuclear  cells  simi- 
lar to  those  found  in  tuberculosis ;  later  it  contains  epithelioid,  and 
occasionally  giant  cells.  This  excites  the  growth  of  the  fixed  con- 
nective tissue  cells,  and  new  connective  tissue  forms  about  the  place 
of  infection ;  these  become  indurated,  and  a  tissue,  made  of  bands  of 
connective  tissue,  soon  passes  in  various  directions ;  the  intervals  are 
filled  with  masses  of  the  streptothrix,  with  zones  of  small,  round, 
mononuclear,  epithelioid  and  giant  cells,  etc.  Sometimes  a  discharge 
of  pus  occurs  near  the  surface,  and  abscesses  frequently  form  in  the 
deeper  tissues.  These  processes  may  be  found  in  connection  with  ex- 
tensive formations  of  connective  tissue  or  not.  In  all  cases  in  which 
the  blood  was  examined  slight  leucocytosis  was  found." 

The  product  of  inflammation  formed  around  each  fungus  is  shown 
by  the  microscope  to  be  composed  in  the  early  stage  of  the  disease  of 
round  cells ;  at  a  later  stage  the  cells  are  epithelioid  in  character,  and 
often  giant  cells  are  found  in  the  infiltration,  associated  with  extensive 
connective-tissue  proliferation,  and  but  for  the  presence  of  the  specific 
organism  the  growth  might  be  mistaken  for  sarcoma. 


ACTINOMYCOSIS    IIOMINIS. 


353 


Water  or  weak  solutions  of  sodium  chlorid  cause  the  fungus  to 
swell  enormously  and  lose  their  shape ;  ether  and  chloroform  have  no 
effect  upon  them.     (Sarjou.) 

Syiiiptoiiis  and  Diagnosis. — Actinomycosis  is  an  affection  of  an 
intiammatory  nature,  with  a  marked  tendency  to  chronicity;  it  is,  how- 
ever, occasionally  very  rapid  in  its  progress.  The  affection  first  ap- 
pears as  an  induration  or  swelling  with  marked  absence  of  pain  or 
tenderness  and  no  elevation  of  temperature.  "The  specific  product, 
composed  of  granulation  tissue,  is  abundant,  and  the  swelling,  often 

Fig.  131. 


Actinomycosis  of  the  Neck.     (lUich.) 


of  considerable  size,  resembles  more  a  tumor  than  an  inflammatory 
swelling.  The  extension  of  the  morbid  process  takes  place  by  eft'usion 
of  the  actinomyces  in  loco,  in  preference  along  the  loose  connective- 
tissue  spaces,  each  fungus  constituting  a  nucleus  for  a  nodule  of  granu- 
lation tissue.  By  confluence  of  many  such  nodules  the  inflammatory 
sw^elling  often  attains  a  very  large  size,  and  when  suppuration  occurs 
in  the  interior  the  further  history  is  that  of  chronic  abscess."  (Senn.) 
Induration  of  the  lymphatic  glands  in  the  immediate  neighborhood  of 
the  diseased  area  indicates  secondary  infection,  but  rarely  general  dis- 

24 


354 


SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 


semination  of  the  affection.  (Fig.  131.)  Exceptionally  the  disease 
pursues  a  rapid  course,  and  under  such  circumstances  the  affection  may 
be  mistaken  for  "an  acute  phlegmonous  inflammation,  osteomyelitis,  or, 
when  diffused  over  a  large  surface  of  the  body,  for  syphilis."  (Senn.) 
Clinically,  actinomycosis  closely  resembles  the  malignant  tumors, 
as  it  invades  all  tissues  with  which  it  conTes  in  contact,  regardless  of 
their  anatomical  structure.  It  spreads  most  rapidly  in  the  loose  con- 
nective tissue,  but  all  the  tissues  of  the  body  are  destroyed  by  the  action 
of  the  fungus  as  soon  as  they  are  invaded. 

Fig.  132. 


ACTINO.MYCOSIS   OF   THE    ChEEK.       (Illich.) 

In  actinomycosis  of  the  jaws,  extensive  destruction  of  bone  takes 
place  and  large  abscesses  are  formed  which  communicate  with  the 
primary  lesion.  The  formation  of  the  abscesses  is  due  to  secondary 
infection  of  the  tumor  with  the  pyogenic  micro-organisms.  This  infec- 
tion with  the  pyogenic  organisms  produces  an  elevation  of  temperature 
ranging  from  100°  to  102°  F.  Redness  of  the  tumor  indicates  the 
extension  of  the  disease  to  the  skin.  Infection  with  the  pyogenic  organ- 
isms is  usually  the  result  of  a  break — perhaps  of  minute  size — in  the 


ACTINOMYCOSIS    HOMINIS.  355 

continuity  of  the  surface  of  the  sweHing.  When  suppuration  is  estab- 
lished the  gn)\\th  increases  in  size  very  rapidly;  diffusion  is  hastened 
by  the  breaking"  down  of  the  granulation  tissue,  which  permits  a  more 
rapid  migration  of  the  fungus. 

The  diagnostic  signs  of  actinomycosis  are  not  well  marked  until 
the  suppurative  stage  has  been  established.  The  discovery  of  the 
characteristic  yellowish,  millet-seed-like,  calcareous  granules  is  the 
only  positive  diagnostic  sign  of  the  disease.  Upon  the  establishment 
of  the  suppurative  process  numerous  sinuses  are  formed  from  which 
pus  escapes  in  considerable  quantity,  and  when  located  in  the  lower 
jaw  the  tissues  of  the  floor  of  the  mouth,  of  the  cheek,  and  of  the  neck 
are  often  involved.  (Fig.  132.)  Trismus  and  swelling  of  the  masseter 
and  temporal  muscles  is  an  early  symptom  when  the  disease  is  located 
in  the  lower  jaw.  The  disease  in  its  earlier  stages  may  be  mistaken  for 
sarcoma,  carcinoma,  tuberculosis,  or  syphilis.  In  the  more  acute 
form  it  may  be  mistaken  for  acute  phlegmonous  inflammation  or 
osteomyelitis.  The  lesions  produced  by  the  ray-fungus  are  so  similar 
in  histologic  structure  to  those  of  sarcoma,  tuberculosis,  and  syphilis, 
that  it  w'ould  be  difficult  to  differentiate  the  disease  from  these  affections 
except  by  the  discovery  of  the  actinomyces  imbedded  in  the  granulation 
tissue.  Occasionally  the  organism  cannot  be  detected  in  the  granulation 
tissue  of  the  tumor ;  it  then  becomes  necessary  in  the  absence  of  this 
proof  to  resort  to  therapeutic  measures  to  clear  up  the  diagnosis  be- 
tween actinomycosis  and  syphilis. 

Pi'ogjiosis. — Actinomycosis  is  an  exceedingly  grave  disease  and  in 
its  nature  and  serious  character  may  be  classed  with  the  malignant 
tumors.  The  gravity  of  the  disease  will  be  in  proportion  to  the  rapidity 
of  the  suppurative  process.  Actinomycosis  of  the  upper  jaw  is  more 
serious  than  when  the  disease  is  in  the  lower  jaw  by  reason  of  the  fact 
that  in  the  former  there  is  a  greater  tendency  to  penetrate  the  deeper 
structures. 

Primary  actinomycosis  of  the  external  tissues  and  other  portions  of 
the  body  that  may  be  reached  by  the  surgeon's  knife  are  susceptible  to 
cure.  The  disease,  however,  has  no  tendency  to  a  spontaneous  cure, 
while,  when  the  primary  affection  is  located  in  the  internal  organs,  it 
almost  without  exception  terminates  fatally.  In  those  cases  which  are 
inaccessible  to  surgical  treatment,  numerous  fistulous  openings  are 
formed,  from  which  pus  is  discharged  in  profuse  quantities,  and  the 
patient  dies  from  pyemia,  sepsis,  amyloid  degeneration  of  vital  organs, 
or  exhaustion,  in  from  one  to  three  years.  The  prognosis  is  usually 
favorable  in  those  cases  which  are  accessible  to  surgical  treatment  and 
in  which  operative  measures  are  instituted  early  in  the  history  of  the 
disease,  and  complete  removal  of  all  infected  tissue  is  secured. 

Murphy  gives  the  following  statistics  in  reference  to  the  prognosis 


356  SURGERY    OF    THE    FACE,    MOUTH,    AND   JAWS. 

of  actinomycosis.  Recoveries  in  the  external  forms  of  the  disease,  70 
per  cent.;  recoveries  in  the  internal  forms,  18  per  cent., — the  average 
mortality  of  the  disease  being  60  per  cent. 

Treatment. — The  treatment  of  actinomycosis  of  the  jaw  consists 
of  a  thorough  surgical  removal  of  all  infected  tissue,  the  employment  of 
suitable  antiseptics,  and  drainage.  As  soon  as  the  diagnosis  of  actin- 
omycosis has  been  established,  immediate  operation  should  be  advised. 
The  operation  consists  of  an  incision  carried  at  least  half  an  inch 
beyond  the  granulation  tissue,  the  excision  of  the  mass  and  thorough 
curetting  of  the  surface,  careful  search  being  made  in  all  directions 
for  hidden  foci  of  the  disease.  All  suspicious  tissue  should  be  removed 
with  the  curette,  the  knife,  and  the  scissors,  and  then  cauterized  with 
the  actual  cautery  or  chromic  acid.  After  thorough  irrigation  with 
strong  solutions  of  carbolic  acid  or  mercuric  chlorid,  the  wound  should 
be  packed  with  iodoform  gauze  and  free  drainage  provided  for.  The 
wound  should  be  kept  open  for  some  time,  and  its  surface  carefully 
inspected  at  each  dressing  for  any  appearance  of  local  recurrence. 
Such  evidences,  if  they  appear,  should  be  immediately  removed  and  the 
surface  again  cauterized.  On  account  of  the  difficulty  often  experi- 
enced in  removing  all  of  the  infected  tissue,  especially  in  the  deeper  por- 
tions of  the  tumor  where  the  bone  has  been  involved,  great  care  should 
be  exercised  to  follow  every  indication  of  an  extension  of  the  disease 
in  the  cancellated  structure  of  the  bone.  Under  no  circumstances 
should  the  wound  be  closed  until  the  entire  surface  is  covered  with 
healthy-appearing  granulation  tissue.  If  the  wound  is  too  extensive 
to  be  closed  by  suturing,  it  may  be  permitted  to  fill  up  by  granulation 
tissue,  and  the  defect  in  the  skin  remedied  by  skin-grafting  after  the 
method  of  Thiersch. 

Billroth  and  Illich  claim  to  have  observed  a  reaction  from  the  in- 
jection of  Koch's  tuberculin.  Ponfick  was  unable  to  confirm  these  ob- 
servations. 

Ponfick  (1898)  recommended  the  injection  of  mercuric  chlorid  i 
to  500,  repeated  several  times  in  those  cases  in  which  the  disease  is  not 
well  marked. 

Thomassen  (1885-6)  recommended  the  administration  of  potas- 
sium iodid  to  animals  and  found  it  always  sufficient. 

Rydygier  (1895)  treated  two  cases  successfully  by  parenchym- 
atous injection  of  a  one  per  cent,  solution  of  potassium  iodid. 

Vallas  (1897)  insisted  that  the  injection  of  potassium  iodid  in  man 
had  but  little  effect,  and  that  mercuric  chlorid  showed  the  best  results. 

Camus  (1899)  says:  "The  iodin  treatment  alone  often  succeeds 
with  animals ;  in  man  it  should  be  supplemented  by  surgical  interven- 
tion (incisions,  curetting,  and  cauterization)." 

Ochsner  (1899)  says:   "In  all  cases  where  the  infected  tissue  was 


ACTINOMYCOSIS    HOMINIS.  357 

not  in  large  masses,  the  patients  recovered  1)y  exactly  the  same  treat- 
ment as  that  given  to  animals,  viz,  potassium  iodid."  He  prescribed 
a  dram  of  the  drug  three  times  per  day  for  as  many  days  as  the  pa- 
tient could  endure  it ;  then  withdrew  the  drug  and  repeated  it  again 
until  the  patient  was  well. 

Sawyers  (1901)  strongly  recommends  the  administration  inter- 
nally of  potassium  iodid  and  of  parenchymatous  injections  of  one  per 
cent,  solution  of  the  drug,  15  minims  to  each  dose. 

In  the  administration  of  potassium  iodid  the  consensus  of  opinion 
is  that  the  drug  should  be  given  in  large  doses,  and  for  a  sufficient 
period  to  produce  decided  iodism. 


CHAPTER    XXXVI. 

DISEASES  OF  THE  MAXILLARY  SINUS. 

The  Maxillary  Sinus,  or  Antntvi  of  Highmore,  is  a  cavity  in  the 
body  of  the  superior  maxillary  bone,  somewhat  pyramidal  in  form,  hav- 
ing its  base  at  the  nasal  fossa,  and  its  apex  directed  toward  the  maxil- 

FiG.  133. 


Left  Superior  Maxillary  Bone,  exhibiting  the   Communications  between  Antrum  and 

Nasal  Cavity.    (After  Zuckerkandl.) 
.  O,  orbital  cavity  ;  H,  maxillary  cavity  of  antrum  of  Highmore;  M  ,  slit-like  opening  ostium  max- 
illare  ;  A,  accessory  opening  between  antrum  and  nasal  cavity. 

lary  tuberosity.     (Fig.   133.)     It  communicates  with  the  nasal  cavity 
by  an  irregular  opening  in  the  external  wall  of  the  middle  meatus. 
Through  this  opening  the  mucous  membrane  of  the  nasal  cavity,  the 
Schneiderian  membrane,  passes  to  line  the  sinus. 
358 


DISEASES    OF    THE    MAXILLARY    SINUS. 


359 


The  maxillary  sinus  has  five  walls;  an  internal,  which  is  the  lateral 
wall  of  the  nasal  cavity  and  forms  the  base  of  the  pyramid  (Fio^.  134)  ;  an 
antero-external,  which  is  the  antero-external  portion  of  the  body  of  the 
superior  maxillary  bone;  a  superior,  which  is  the  floor  of  the  orbit;  a 
posterior,  which  is  that  portion  of  the  superior  maxillary  bone  that 
articulates  with  the  pterygoid  process  of  the  sphenoid  bone;  and  an 
inferior,  which  is  that  part  of  the  superior  maxillary  bone  from  which 
arises  the  alveolar  process.  The  thinnest  and  most  inferior,  or  de- 
pendent portion  of  this  wall,  is  opposite  the  alveoli  of  the  second  molar 
tooth.  The  floor  of  the  antrum  has  generally  an  uneven  surface,  the 
eminences  corresponding  to  the  roots  of  the  teeth.  Occasionally  the 
roots  of  the  first  and  second  molars  penetrate  the  floor  of  the  sinus. 

Fig.  134. 


Inferior  Surface  of  the  Right  Superior  Maxillary  Bone. 
P,  palate  process  ;  S,  anterior  nasal  spine  ;  M,  lower  meatus  of  nasal  cavity  ;  L,  lachrymal  groove  ; 

A,  antrum  of  Highmore. 


Bony  septa  are  frequently  found  crossing  the  floor  from  side  to  side. 
The  septa  rarely  extend  higher  than  one-fourth  to  one-third  of  the  dis- 
tance from  the  floor  to  the  roof  of  the  sinus.  The  sinus  has  a  capacity 
of  from  two  drachms  to  one  ounce,  or  even  more. 

The  other  accessory  cavities  which  open  into  the  nasal  passages 
are  the  frontal  and  sphenoidal  sinuses.  The  frontal  sinuses  are  two 
irregular  cavities  situated  between  the  plates  of  the  frontal  bone,  on 
either  side  of  the  median  line.  They  are  not  present  in  childhood,  but 
are  fully  developed  in  adult  life.  They  communicate  with  the  nares  by 
a  rounded  canal,  which  opens  into  the  middle  meatus,  and  is  called  the 
infundibulum.  The  accompanying  Roentgen-ray  picture  (Fig.  135), 
female  head,  shows  the  outlines  of  the  frontal  and  maxillary  sinuses  and 


36o 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


the  orbits.  Cryer  has  shown,  in  a  paper  read  before  the  American 
Dental  Association  in  1895,  illustrated  by  the  stereopticon  and  pub- 
lished in  the  Dental  Cosmos  for  January,  1896,  that  the  infundibulum 
often  discharges  directly  into  the  antrum,  and  in  others  so  near  to  the 
ostium  maxillare  that  it  might  discharge  into  it.  This  was  a  new  dis- 
covery, and  goes  far  toward  an  explanation  of  the  difficulties  often 

Fig.  135. 


Female  Head,  showing  Sinuses. 


encountered  in  the  treatment  of  antral  inflammation.  In  describing 
this  newly-discovered  relationship  and  in  explanation  of  Figs.  136  and 
137,  he  says  this  ''is  a  sagittal  section  made  near  the  inner  wall  of  the 
orbit.  The  frontal  sinus  is  seen  at  the  top,  and  below  this  is  the  inner 
wall  of  the  orbit,  os  planum  of  the  ethmoid,  including  the  edge  of  the 
inner  portion  of  the  floor,  below  which  is  the  internal  wall  of  the  max- 
illary sinus.     ...     To  locate  the  opening  and  the  direction  in  which 


DISEASES   OF    THE    MAXILLARY    SINUS. 


361 


the  excess  of  fluid  would  pass  from  the  sinus,  a  wire  has  been  passed 
backward  into  the  hiatus  semikmaris.  A  perpendicular  probe  passes 
through  the  upper  portion  of  the  opening  of  the  sinus,  which  in  this 
case  is  partly  in  its  roof  or  at  the  angle  of  the  internal  wall  and  the  roof; 
as  the  straight  probe  passes  out  of  the  antrum,  it  passes  through  the 
infundibulum  into  the  frontal  sinus,  showing-  that  fluids  could  pass 
directly  downward  from  the  frontal  into  the  maxillary  sinus."  These 
specimens  also  show  "where  the  anterior  ethmoidal  cells  open  just  at 

Fig.  136. 

Probe  passing:  frontal  sinii<;. 


Superior  maxilla. 


Probe  passing  irontal  sinus.     (After  Cryer.) 


the  maxillary  sinus.  If  the  hiatus  semilunaris  should  be  closed  by 
pressure  of  the  septum  or  inflammation  of  the  mucous  membrane,  the 
fluids  from  the  frontal  and  ethmoidal  cells  would  pass  into  the  antrum." 
Fillebrown,  in  a  paper  read  before  the  American  Dental  Association 
in  1896,  and  published  in  the  Dental  Cosmos  for  November,  1896,  states 
it  as  his  opinion  that  in  certain  obstinate  chronic  cases  of  empyema  of 
the  antrum,  the  frontal  sinuses  are  also  affected,  and  that  the  inflamma- 
tory secretions  from  these  sinuses  drain  into  the  antra,  and  thus  keep 
up  the  inflammator}'  conditions  of  the  latter  sinuses.     But  inasmuch 


362 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS, 


as  such  a  supposition  was  contrary  to  the  accepted  opinion  upon  the 
subject,  and  also  not  in  accord  with  the  generally  accepted  teaching  as 
to  the  anatomical  relations  of  the  parts,  he  instituted  a  line  of  investi- 
gation in  order  to  demonstrate  the  correctness  or  the  possible  error 
as  to  the  relations  of  the  infundibulum  and  the  point  at  which  it 
discharged  its  secretion.     The  text-books  'on  anatomy  state  that  the 

Fig.  137. 


4  ,'■■■ 


i..1^"\^ 


Infundibulum t 


Opening  max- 
illary sinus. 


Superior  Maxilla.     (After  Cryer.) 

infundibulum  terminates  in  the  middle  meatus  of  the  nose,  but  Fille- 
brown's  investigations  do  not  bear  out  the  correctness  of  this  state- 
ment, for  he  has  found  in  eight  subjects,  taken  at  random,  that  in  every 
one  the  frontal  sinuses  communicated  directly  with  the  antra,  thus  cor- 
roborating the  investigations  of  Cryer.  He  says,  "The  infundibulum, 
instead  of  terminating  directly  in  the  middle  meatus,  continues  as  a 
half-tube,  this  half-tube  terminating  directly  in  the  foramen  of  the 
maxillary  sinus.     In  seven  of  the  specimens  there  was  a  fold  of  mucous 


DLSKASKS    OF    TllK    MAXILLARY    SINUS. 


363 


membrane  which  served  as  a  continuation  of  the  unciform  process  and 
reached  upward,  covering  the  foramen  and  forming  a  pocket  which  ef- 
fectually prevented  any  secretion  from  the  frontal  sinus  getting  into 
the  meatus  until  the  antrum  and  pocket  were  full  to  overflowing." 

Dr.  Fillebrown  further  thinks  that  this  pocket  cannot  be  an  an- 
omaly, as  thought  by  some  other  observers,  it  being  found  in  seven  out 
of  eight  subjects,  but  that  its  absence  might  be  considered  anomalous, 

Fig.  138. 


Middle  turbinate  cut  away. 


Infundibulum. 


(After  Fillebrown.) 


rather  than  the  usual  type.  Figs.  138,  139,  and  140  illustrate  the  points 
made  by  the  author  of  the  paper. 

The  sphenoidal  sinuses  are  tw^o  cavities  hollowed  out  in  the  body 
of  the  sphenoid  bone,  and  are  separated  from  each  other  upon  the 
median  line  by  a  thin  lamella  of  bone.  These  sinuses  are  also  lined 
with  mucous  membrane. 

Diseases  of  the  maxillary  sinus  are  quite  common,  much  more  so 
than  is  generally  supposed.  These  diseases  are  more  common  among 
the  lower  classes  of  society,  especially  those  who  give  no  attention  to 


364 


SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 


the  care  of  their  teeth.  Abundant  proof  of  this  statement  can  be  found 
in  any  of  the  surgical  cHnics  in  the  free  dispensaries  and  hospitals  of 
our  large  cities. 

Climatic  influences  are  important  factors  also  in  the  production  of 
certain  forms  of  antral  disease.  Mucous  engorgements,  and  empyema, 
are  much  more  prevalent  in  damp  and  changeable  climates,  where 
catarrhal  conditions  abound,  than  in  dry  or  equable  climates. 


Fig.  139. 


Frontal  sinus 


Infundibulum 


Antrum. 


(After  Fillebrown.) 


The  diseased  conditions  most  commonly  found  afifecting  the  max- 
illary sinus  are : 

I  St.     Suppurative  inflammation,  or  purulent  empyema. 

2d.     Mucous  engorgements. 

3d.     Syphilitic  ulceration. 

4th.    Necrosis  of  the  bony  walls. 

5th.    Tumors. 

Suppurative  Inflammation  of  the  Maxillary  Sinus. — Suppura- 
tive inflammation  of  the  antrum  is  the  most  common  of  all  diseases 


DISEASES   OF   THE    MAXILLARY    SIXUS. 


365 


affecting-  this  sinus.  It  is  not  an  idiopathic  affection.  It  may  be 
acute,  subacute,  or  chronic.  In  the  acute  form  there  is  rarely  any 
difficulty  in  making  a  correct  diagnosis,  but  in  the  chronic  very  great 
difficulty  is  sometimes  encountered,  owing  to  the  fact  that  the  symp- 
toms are  rarely  well  marked,  and  so  closely  simulate  chronic  nasal 
catarrh  as  to  be  easily  mistaken  for  that  affection.  The  disease  may 
be  unilateral  or  bilateral.     It  is  extremely  rare  that  both  antra  are 


Fig.  140. 


Frontal  sinus. 


Superior  turbinate. 


Pocket. 
Middle  turbinate. 


Inferior  turbinate. 


After  Fillebrown.) 


found  affected  at  the  same  time.  Two  cases  only  of  bilateral  disease 
have  ever  come  under  the  personal  observation  of  the  writer.  The 
first  was  a  German  woman  about  forty  years  of  age,  who  presented 
herself  at  the  clinic  of  the  Post-Graduate  Medical  School  of  Chicago. 
Both  antra  were  engorged  with  purulent  secretions,  the  face  much 
swollen  in  the  infraorbital  region,  the  left  somewhat  more  than  the 
right;  parchment-like  crepitation  was  present  over  both  antra,  and 
bulging  of  the  palate  process  upon  both  sides.     There  was  consider- 


366  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

able  protrusion  of  the  left  eye,  but  this  condition  was  not  so  marked  in 
the  right;  she  complained  of  impaired  vision.  The  superior  teeth  were 
all  decayed  to  the  gums.  This  case  was  due  to  the  infection  of  the 
antra  with  pus  from  several  alveolar  abscesses  upon  both  sides  of  the 
jaw. 

The  second  was  a  recent  case,  in  the  person  of  a  professional 
friend,  in  which  the  disease  followed  an  attack  of  la  grippe,  producing  a 
mucous  engorgement  of  both  antra,  and  loss  of  the  voice  as  a  compli- 
cation. This  at  least  was  the  opinion  of  the  patient,  and  it  proved  to 
be  correct,  for  immediately  after  draining  the  antra  the  laryngeal  symp- 
toms began  to  improve.     This  case  made  a  quick  recovery. 

Etiology. — The  causes  of  suppurative  inflammation  of  the  maxil- 
lary sinus  generally  arise  from  one  of  the  following  local  conditions: 

Diseases  of  the  teeth, 

Presence  of  foreign  bodies  in  the  sinus, 

Traumatic  injuries. 

Catarrhal  affections. 

The  diseases  of  the  teeth  which  may  give  rise  to  suppurative  in- 
flammation of  the  antrum  are  often  of  a  more  or  less  obscure  nature, 
frequently  requiring  considerable  skill  in  special  diagnosis  to  arrive  at 
a  correct  solution  of  the  difficulties  presented  in  certain  cases.  It  is 
therefore  no  wonder  that  the  general  practitioner  of  medicine  or  of 
dentistry  should  sometimes  fail  to  make  a  correct  diagnosis. 

The  lesions  of  the  teeth  which  may  be  classed  as  active  causes  in 
the  production  of  suppurative  inflammation  of  this  sinus  are, — 

(a)  Devitalized  pulps. 

(b)  Alveolar  abscesses. 

(c)  Malposed  teeth. 

Devitalized  Pulps. — A  devitalized  pulp  in  the  root  of  a  tooth  which 
penetrates  the  floor  of  the  antrum  may  give  rise  to  a  septic  inflamma- 
tion of  the  lining  membrane  of  this  cavity  from  the  escape  of  the  lique- 
fied and  putrescent  pulp-tissue  and  mephitic  gases,  without  giving  the 
least  evidence  of  the  real  cause  of  the  trouble  other  than  a  slight  discol- 
oration of  the  tooth. 

Cases  of  this  character  are  by  no  means  uncommon,  while  the 
obscurity  of  the  cause  of  the  difficulty  makes  it  doubly  interesting  from 
the  diagnostic  point  of  view.  Cases  of  this  obscure  nature  have  fre- 
quently come  under  the  observation  of  the  writer,  which  had  been  ex- 
amined by  some  of  the  very  best  general  practitioners,  without  finding 
the  cause.  The  difficulty  in  the  diagnosis  is  greatly  augmented  if 
there  are  several  devitalized  teeth  and  roots  in  the  afifected  side  of  the 
jaw.  The  location  of  the  offending  tooth  then  becomes  a  matter  of 
conjecture,  and  there  is  no  certainty  of  making  a  cure  except  by  the  ex- 
traction of  all  teeth  which  have  lost  their  vitality,  that  may  be  associ- 
ated with  the  diseased  antrum. 


DISEASES    OF    THE    MAXILLARY    SINUS.  367 

Sometimes  the  offending  tooth  will  be  of  such  good  color  as  to 
appear  to  the  eye  like  a  living  tooth,  and  thereby  be  overlooked. 
There  are  three  methods  of  diagnosing  pulpless  or  devitalized  teeth  : 
one  is  to  reduce  the  temperature  by  the  application  of  a  piece  of  ice.  If 
the  tooth  be  vital,  the  great  change  in  temperature  will  cause  pain;  or 
the  temperature  may  be  reduced  by  throwing  upon  the  suspected  tooth 
a  spray  of  ether.  A  second  is  to  illuminate  the  mouth  with  the  electric 
lamp,  the  patient  being  seated  in  a  dark  room.  The  living  teeth  will 
transmit  the  light  very  readily,  the  devitalized  teeth  will  not,  the  differ- 
ence in  the  translucency  being  very  marked.  A  third  is  to  apply  the 
Faradic  current.  The  devitalized  teeth  will  give  no  response,  while 
the  living  teeth  will  be  very  sensitive  to  the  shock.  This  latter  method 
has  been  used  by  the  writer  for  many  years,  and  experience  teaches 
that  it  is  the  most  reliable,  as  he  has  never  failed  to  make  a  correct 
diagnosis  by  this  method. 

Alveolar  Abscesses. — Devitalized  pulps,  under  ordinary  circum- 
stances, if  not  interfered  with  surgically,  usually  result,  sooner  or  later, 
in  the  development  of  alveolar  abscesses.  A  devitalized  pulp  in 
the  roots  of  a  superior  bicuspid  or  molar,  which  results  in  the  formation 
of  an  alveolar  abscess,  may  on  account  of  the  thinness  of  the  floor  of 
the  antrum  at  these  locations  point  into  the  sinus,  and  thus  establish 
a  suppurative  inflammation. 

An  alveolar  abscess  which  discharges  into  the  antrum  of  Highmore 
is  the  most  common  factor  in  the  production  of  suppurative  conditions 
of  this  sinus.  The  association  between  the  alveolar  abscess  and  the 
inflammatory  conditions  of  the  sinus  is  sometimes  quite  obscure.  The 
patient  will  frequently  give  a  history  of  an  abscessed  tooth  which  was 
troublesome  for  a  week  or  ten  days,  and  then  the  symptoms  subsided. 
Later,  whenever  a  cold  is  taken,  the  tooth  is  a  little  tender.  Some- 
times there  is  a  bad-smelling  discharge  from  the  nose  as  the  only  symp- 
tom. Another  case  will  present  all  of  the  characteristic  symptoms  of 
the  disease,  and  the  offending  tooth  will  be  readily  recognized. 

Devitalized  pulps  and  alveolar  abscesses  cause  suppurative  inflam- 
mation of  the  antrum  by  septic  infection,  and  often  produce  marked 
symptoms  during  the  acute  stage  of  general  septic  intoxication.  When 
the  latter  condition  is  present,  it  calls  for  speedy  and  heroic  treatment, 

Malposed  Teeth. — Malposed  teeth  are  often  found  in  locations 
where  it  is  impossible  for  them  to  take  their  normal  position  in  the 
alveolar  arch ;  in  fact,  they  are  found  in  almost  every  conceivable  posi- 
tion, and  with  every  line  of  inclination.  Occasionally  they  are  found 
lying  near  the  floor  of  the  antrum,  in  a  longitudinal  direction,  or  even 
with  an  upward  inclination.  Fig.  141  is  from  a  cast  showing  the  mal- 
position of  the  superior  cuspids,  which  were  lying  close  to  the  floor  of 
the  antrum.     Fig.  142  indicates  the  relative  position  which  they  occu- 


368 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


pied  to  each  other.  More  rarely  they  have  been  found  completely 
inverted.  Under  these  conditions  a  suppurative  inflammation  may 
be  established  as  a  direct  cause  of  the  irritation  produced  by  the  effort 
on  the  part  of  nature  to  complete  the  development  of  the  tooth,  and 

Fig.  141. 


Malposition  of  the  Cuspid  Teeth  in  Woman  Forty-five  Years  of  Age. 

Fig.  142. 


Positions  occupied  by  the   Cuspid  Teeth  in  the  Jaw. 

force  it  from  its  bony  crypt.  As  the  pus  increases  in  quantity,  the 
surrounding  bony  walls  grow  thinner  and  eventually  give  way  upon 
the  side  offering  the  least  resistance.  When  this  side  of  least  resist- 
ance happens  to  be  the  floor  of  the  antrum,  the  pus  is  discharged 


DISEASES    OF    THE    MAXILLARY    SINUS.  369 

into  this  sinus,  establishing  an  inflammatory  condition  of  its  lining 
mucous  membrane,  which  may  go  on  indefinitely  if  not  relieved  by 
surgical  treatment. 

Tyler  reports  (Southern  California  Practitioner,  June,  1899)  a 
case  in  which  a  malposed  tooth  was  found  located  in  the  nasal  septum, 
the  root  inclining  downward  but  not  penetrating  the  roof  of  the  mouth. 
It  extended  horizontally,  directly  across  the  nasal  cavity,  with  its 
crown  imbedded  in  the  inferior  turbinated  bone. 

A  remarkable  case  of  this  character,  occurring  in  the  family  of  a 
professional  acquaintance,  and  coming  under  the  knowledge  of  the 
writer,  is  of  interest  in  this  direction.  Mrs.  G.,  mother  of  the  doctor, 
had  for  sixteen  years  been  troubled  with  an  offensive  discharge  from 
the  left  nostril.  Prior  to  this  she  had  suffered  intensely  from  pain  and 
swelling  in  the  region  of  the  left  antrum,  which  lasted  for  several 
weeks,  and  then  subsided.  This  condition  was  accompanied  by  a  pro- 
fuse discharge  of  offensive  secretions  from  the  left  nostril.  Later  the 
swelling  disappeared,  but  the  discharge  never  wdiolly  ceased.  Six 
years  after  the  first  attack,  the  face  again  became  very  painful  and 
much  swollen,  this  time  extending  farther  backward  toward  the  ear, 
finally  developing  what  was  thought  to  be  abscess  of  the  middle  ear. 
Large  quantities  of  pus  were  discharged  from  the  ear,  and  at  one  time 
it  was  feared  that  the  suppurative  process  would  extend  to  the  menin- 
ges of  the  brain.  After  several  weeks  of  intense  suffering  the  symp- 
toms again  subsided,  and  finally  the  discharge  entirely  ceased  from  the 
ear.  After  this,  however,  the  discharge  from  the  nose  seemed  to  be 
increased,  and  the  symptoms  were  always  aggravated  by  taking  cold. 
The  teeth  of  the  left  side  of  the  upper  jaw  had  all  been  extracted  as  a 
possible  cause  of  the  trouble,  except  the  third  molar,  which  had  never 
erupted.  This  procedure,  however,  produced  no  abatement  of  the 
symptoms.  Later,  the  teeth  of  the  opposite  side  were  removed  for  the 
purpose  of  inserting  a  complete  upper  artificial  denture.  About  ten 
years  after  the  last-mentioned  attack,  while  leaning  over  a  washbowl, 
"brushing  her  teeth,  she  suddenly  noticed  that  the  left  nostril  was 
plugged  up  with  some  movable  body.  On  throwing  the  head  back,  in 
an  attempt  to  dislodge  it,  the  mass  fell  into  the  fauces,  and  was  ejected 
from  the  mouth  into  the  bowd.  Upon  examination,  it  proved  to  be  a 
well-developed  left  superior  third  molar,  more  or  less  covered  with 
hard  concretions  of  a  dark  brown  color.  The  discharge  from  the  nose 
from  this  time  on  gradually  grew  kss,  and  finally,  after  a  few  months, 
ceased  altogether. 

The  probable  explanation  of  the  peculiar  features  of  this  case  are, 
briefly:  First,  the  third  molar  was  developed  in  an  inverted  position, 
and  very  near  to  the  floor  of  the  antrum ;  second,  suppurati-ve  inflam- 
mation was  established  in  the  crypt  of  the  tooth-germ  from  irritation 

25 


370  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

induced  by  its  development  in  an  abnormal  position;  third,  the  pus- 
cavity  ruptured  into  the  antrum;  fourth,  the  abscess  which  ruptured 
into  the  middle  ear  may  have  been  caused  by  the  tooth,  though  there 
is  some  doubt  as  to  this,  as  the  anatomy  of  the  parts  would  not  favor 
such  a  supposition.  The  tooth  probably  became  dislodged  at  this  time, 
and  escaped  into  the  antrum;  fifth,  at  a  later  period  it  must  have  be- 
come lodged  against  the  nasal  wall  of  the  antrum,  causing  ulceration, 
which  finally  permitted  it  to  pass  into  the  nasal  cavity,  and  thus  be 
expelled. 

Foreign  Bodies. — Foreign  bodies  of  various  materials  are  occa- 
sionally met  with  in  the  antrum  as  a  cause  of  disease.  Those  most  com- 
monly found  are  the  roots  of  teeth  which  have  slipped  from  the  forceps 
and  escaped  into  the  sinus  through  an  enlarged  alveolus  in  attempting 
to  extract  them;  malposed  teeth  which  have  erupted  into  it,  or  have 
found  entrance  through  pathologic  conditions;  fragments  of  bone  or 
of  teeth  which  have  been  forced  into  it  by  some  crushing  injury  of  the 
walls  of  the  antrum;  portions  of  lead  or  other  metal  which  have  lodged 
there  as  a  result  of  gunshot  injuries;  and  pai tides  of  food  which  have 
found  entrance  through  some  artificial  opening  that  has  been  made  for 
the  treatment  of  a  pre-existing  diseased  condition. 

The  presence  of  any  foreign  substance  is  usually  productive  of 
inflammatory  conditions  of  the  lining  mucous  membrane,  resulting  in 
subacute  or  chronic  inflammation,  with  purulent  discharge,  or  of  en- 
gorgement and  protrusion  of  the  walls,  with  possibly  graver  conse- 
quences. 

When  there  is  no  positive  history  of  the  entrance  of  such  foreign 
bodies,  the  diagnosis  sometimes  becomes  exceedingly  difficult,  and 
can  only  be  reached  by  a  critical  examination  of  every  feature  and 
symptom  of  the  disease,  one  by  one  excluding  those  causes  which  do 
not  give  a  marked  history,  then  from  the  remaining  possible  etiologic 
factors,  by  a  still  closer  analysis  and  exclusion,  arrive  at  a  correct  diag- 
nosis. 

The  diagnosis  being  assured,  operative  measures  are  necessary. 
These  measures  comprehend  the  making  of  an  opening  into  the  an- 
trum, the  search  for  the  foreign  body,  and  its  removal. 

The  selection  of  the  point  at  which  to  open  the  antrum  should  be 
governed  by  the  surrounding  conditions.  The  unnecessary  sacrifice 
of  sound  teeth  in  order  to  gain  easy  access  to  it  does  not  com.mend 
itself  to  a  wise  conservatism.  In  the  extraction  of  teeth  for  this  pur- 
pose those  should  be  selected  which  from  their  condition  and  location 
are  of  the  least  value  to  the  individual,  provided  only  that  they  are  in 
close  relation  to  the  floor  of  the  antrum.  If  a  bicuspid  or  a  molar  has 
already  been  lost,  it  is  preferable  to  enter  the  antrum  from  this  point 
rather  than  sacrifice  remaining  sound  teeth. 


DISKASKS    OF    THE    MAXILLARY    SINUS.  37I 

Traumatic  Injuries. — Traumatic  injuries  involving  the  maxillarv 
sinus  are  of  rare  occurrence,  and  are  the  result,  generally,  of  gunshot 
wounds  or  crushing  injuries  of  the  face,  causing  fracture  and  comminu- 
tion of  the  superior  maxillary  bones.  Cases  of  this  character  almost 
invariably  terminate  in  suppurative  inflammation, — at  least  this  has 
been  the  observation  of  the  writer.  This  is  explained  by  the  fact  that 
such  injuries  always  produce  compound  fractures  of  the  bone,  and 
when  associated  with  the  oral  cavity  are  always  infected  from  the  secre- 
tions and  alimentary  debris,  consequently  septic  inflammation  is  prone 
to  follow,  as  is  the  case  with  compound  fractures  of  the  lower  jaw 
which  communicate  Avith  the  mouth. 

Disease  of  this  character  is  much  more  amenable  to  treatment,  as 
a  rule,  than  are  those  conditions  which  result  from  disease  of  the  teeth, 
for  the  reason  that  in  the  first  the  inflammation  is  generallv  of  acute 
type,  while  in  the  latter  it  is  usually  subacute  or  chronic;  the  character 
of  the  infection  may  also  be  a  modifying  factor. 

Catarrhal  Affections.— Catarrhal  aiTections  of  the  nasal  mucous 
membrane  often  result  in  the  extension  of  these  conditions  to  the 
frontal,  sphenoidal,  and  maxillary  sinuses.  The  mucous  membrane 
lining  the  accessory  cavities  is  a  reflection  of  the  membrane  which  lines 
the  nasal  passages;  consequently  the  inflammatory  conditions  which 
affect  the  mucous  tissue  of  these  passages  are  quite  likely  to  extend  to 
the  accessory  cavities  which  open  into  them  through  the  continuity  and 
functional  identity  of  their  lining  membrane. 

Mucous  Engorgements. — Among  the  most  common  of  the  catar- 
rhal inflammations  of  the  nasal  passages  which  may  extend  to  the  ac- 
cessory sinuses  and  produce  mucous  engorgements  are  acute  and 
chronic  coryza,  and  la  grippe  or  influenza. 

Mucous  engorgements,  in  the  opinion  of  the  writer,  are  much 
more  likely  to  follow  acute  catarrhal  inflammations  than  the  chronic 
form. 

Acute  coryza,  or  cold  in  the  head,  is  usually  the  result  of  exposure 
to  cold,  though  it  is  occasionally  due  to  the  irritating  effects  of  acrid 
vapors,  or  other  irritating  substances.  It  also  occurs  at  the  com- 
mencement of  certain  of  the  eruptive  fevers,  as  measles,  scarlet  fever, 
etc.,  and  in  rare  cases,  the  breathing  of  the  vapor  of  iodin,  or  of  particles 
of  ipecacuanha  in  those  possessing  peculiar  idiosyncrasies  will  bring  on 
an  attack. 

The  onset  of  an  attack  of  acute  coryza  is  ushered  in  by  varying 
degrees  of  chill,  from  a  slight  chilly  sensation  to  a  pronounced  rigor, 
a  feeling  of  lassitude  and  general  malaise,  followed  by  a  slight  increase 
in  body  temperature,  with  myalgia  and  loss  of  appetite.  The  mucous 
membrane  of  the  nasal  passages  becomes  congested,  accompanied  by 
a  sense  of  burning  and  prickling,  with  a  feeling  of  dryness  and  heat. 


372  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

This  may  last  for  a  few  hours,  or  even  a  couple  of  days,  when  a  watery, 
acrid  discharge  sets  in,  gradually  changing  in  the  course  of  a  few  days 
to  a  thick  yellow  mucus,  more  or  less  copious  in  amount,  and  finally  to 
a  free  discharge  of  a  purulent  character.  The  duration  of  the  attack 
may  be  from  three  or  four  days  to  two  or  three  weeks. 

These  symptoms  are  the  result  first  of  congestion  of  the  mucous 
membrane  and  the  arrest  of  the  secretions  producing  the  characteristic 
dryness.  This  is  followed  by  a  free  transudation  of  the  liquor  san- 
guinis from  the  engorged  blood-vessels,  causing  swelling  of  the  mem- 
brane, and  supplying  the  main  portion  of  the  earliest  secretion,  which 
is  of  a  serous  character.  Later,  the  glandular  structures  are  stim- 
ulated to  an  abnormal  activity,  and  a  profuse  discharge  is  established, 
consisting  of  mucus,  epithelial  cells,  and  leucocytes,  with  a  slight  ad- 
mixture of  red  blood-corpuscles.  As  the  disease  progresses,  the  em- 
bryonic cells  increase  in  numbers,  and  the  secretion  assumes  a  purulent 
character.  When  the  nasal  mucous  membrane  is  alone  affected,  the 
discomfort  is  referable  to  the  nose  only,  and  consists  of  an  increased 
secretion,  sense  of  fullness,  or  complete  occlusion,  due  to  swelling  of 
the  membrane,  and  repeated  and  distressing  attacks  of  sneezing.  If 
the  disease  extends  to  the  frontal  sinuses  there  is  often,  as  a  marked 
symptom,  a  severe  frontal  headache;  when  the  antrum  of  Highmore  is 
involved,  there  is  usually  a  more  or  less  severe  neuralgia,  referred  to 
the  infraorbital  or  malar  region.  If  the  inflammatory  symptoms  are 
severe,  causing  considerable  swelling  and  thickening  of  the  mucous 
membrane,  it  is  likely  to  result  in  the  closure  of  the  openings  into  the 
nasal  passages  of  the  accessory  sinuses,  and  consequent  retention  of 
the  secretions,  followed  by  the  symptoms  described  under  the  head  of 
suppurative  inflammation  of  the  antrum. 

La  grippe  is  frequently  manifested  in  an  acute  inflammation  of  the 
mucous  membrane  of  the  nasal  passages,  which  often  extends  to  the 
accessory  sinuses,  leading  to  mucous  engorgement  and  other  more 
serious  involvement,  especially  of  the  antrum  of  Highmore. 

It  was  the  experience  of  the  writer  in  the  last  epidemic  of  la  grippe 
in  Chicago,  during  the  winter  of  1891-92,  to  treat  a  larger  proportion  of 
cases  of  engorgement  of  the  maxillary  sinuses  as  a  direct  result  of 
attacks  of  this  disease  which  were  principally  confined  to  the  upper  air- 
passages,  than  from  any  other  or  all  other  causes  combined. 

The  prognosis  in  these  cases,  as  in  those  arising  from  acute 
coryza,  is  much  better  than  when  the  cause  is  some  chronic  inflamma- 
tory condition  of  the  mucous  membrane. 

Chronic  coryza  is  the  result  of  repeated  attacks  of  the  acute  dis- 
ease, or  it  may  occasionally  be  of  a  chronic  type  from  the  beginning. 
The  most  prominent  symptom  is  an  increased  secretion  of  mucus,  or  of 
muco-pus,  which   is   discharged  through  the   nose,   or  through  the 


DISEASES    OF   THE    MAXILLARY    SINUS.  373 

pharynx  into  the  mouth.  The  discharge  is  semi-fluid,  having  some- 
what of  a  purulent  character,  on  account  of  the  copious  admixture  of 
embryonic  cells  and  of  epithelial  scales  with  the  mucus.  There  is  no 
marked  thickening-  of  the  mucous  membrane,  and  its  surface  is  at  all 
times  soft  and  moist.  Its  color  is  abnormal,  showing  a  reddened,  con- 
gested appearance,  sometimes  turgid  or  purplish.  The  disease  is 
aggravated  by  changes  in  the  weather,  and  is  more  prominent  in  the 
chilly  spring  and  autumn  days.  Such  conditions,  when  affecting  the 
antrum,  rarely  cause  stenosis  of  the  nasal  opening,  consequently  the 
discharges  escape  from  time  to  time  into  the  nose,  when  the  body 
assumes  a  favorable  position  for  the  drainage  of  the  cavity.  The 
secretions,  as  a  rule,  however,  are  not  discharged  with  sufficient  free- 
dom to  prevent  their  decomposition  and  consequent  fetid  odor,  though 
sufficiently  so  to  prevent  the  sense  of  fullness  or  the  expansion  of  the 
antrum,  so  common  in  those  cases  having  retained  secretions. 


CHAPTER    XXXVII. 

DISEASES  OF  THE  MAXILLARY  SINUS  (Continued). 

Suppuration  of  the  Antrum  of  Highmore. 

Symptoms. — The  symptoms  of  suppuration  of  the  antrum  are 
pain,  which  is  at  first  dull  and  deep-seated,  later  becoming  more  in- 
tense, shooting  over  the  face  and  forehead,  sometimes  including  the 
ear.  Occasionally  the  pain  is  very  acute,  and  of  a  sharp,  stabbing 
character.  The  cheek  becomes  swollen  and  tender;  the  walls  of  the 
antrum  are  thinned,  and  later  give  forth,  under  pressure,  a  crackling 
sound,  like  that  of  crushing  an  egg-shell,  or  of  crumpling  parchment. 
Frequently  there  is  protrusion  of  the  eyeball,  sometimes  accompanied 
by  amaurosis.  This  feature  is  due  to  the  thinning  of  the  floor  of  the 
orbit,  or  roof  of  the  antrum,  and  protrusion  into  the  orbital  cavity, 
which  forces  the  eyeball  outw^ard,  and  causes  paralysis  of  the  optic 
nerve  from  pressure  upon  it.  In  acute  cases,  the  formation  of  pus  is 
ushered  in  with  a  rigor,  followed  by  elevation  of  temperature  and  gen- 
eral systemic  disturbance.  In  the  subacute  and  chronic  forms,  the 
constitutional  symptoms  may  be  entirely  absent.  Generally  there  is 
an  offensive,  purulent  discharge  from  the  nostril  of  the  affected  side; 
this  symptom,  however,  may  not  be  present,  on  account  of  the  closure 
of  the  normal  opening  into  the  nasal  passages,  the  ostium  maxillare, 
from  induration  of  the  lining  mucous  membrane.  In  the  latter  condi- 
tion the  protrusion  of  the  antral  walls  is  usually  much  greater,  and  the 
suffering  induced  by  the  pressure  of  the  pent-up  inflammatory  pro- 
ducts is  often  very  sev^ere.  Sooner  or  later  the  walls  of  the  antrum  are 
absorbed,  the  soft  tissues  are  penetrated,  and  the  fluid  escapes.  The 
location  at  which  the  rupture  of  the  wall  takes  place  is  generally  that 
point  which  offers  the  least  resistance.  This  varies  greatly  in  different 
individuals.  The  most  common  locations  are  the  nasal  wall,  the  palate 
process,  and  the  infraorbital  plate,  or  roof  of  the  antrum.  Occasion- 
ally the  buccal  wall  will  give  way,  or  the  fluid  may  follow  the  root  of  a 
tooth  which  penetrates  the  floor  of  the  antrum,  and  discharges  into  the 
mouth;  more  rarely  it  may  burrow  backward,  after  having  penetrated 
the  floor  of  the  orbit,  and  enter  the  brain  through  the  sphenoidal  fissure 
or  the  optic  foramen.  Rupture  of  the  walls  of  the  antrum  usually 
374 


DISEASES    OF    TllK    MAXILLAKV    SINUS.  375 

causes  considerable  ulceration  and  necrosis,  which  may  involve  the  en- 
tire maxillary  bone.  If  the  discharges  enter  the  cranial  cavity,  epilep- 
tiform convulsions  are  likely  to  be  induced,  with  other  brain-symptoms, 
closelv  followed  by  a  fatal  termination. 

In  those  cases  in  which  the  discharges  escape  into  the  nose,  the 
breath  is  exceedingly  offensive,  having  the  odor  of  a  rotten  egg,  which 
is  due  to  the  presence  of  hydrogen  sulfid  gas,  liberated  by  the  de- 
composition of  the  albuminates  contained  in  the  discharges.  Blow- 
ing the  nose  will  sometimes  relieve  the  sense  of  fullness  by  causing  a 
flow  of  the  discharges.  The  more  common  course  is  for  the  discharge 
to  be  quite  constant,  the  amount  varying  from  a  slight  quantity  to  a 
considerable  amount,  and  flowing  into  the  nose  and- throat  when  lying 
upon  the  unaffected  side.  During  sleep  the  discharges  are  often  swal- 
lowed, producing  nausea  and  sometimes  vomiting  on  rising  in  the 
morning.  The  movements  of  mastication  may  also  cause  a  discharge 
of  the  pent-up  secretions  while  taking  food,  and  thereby  induce  nausea 

and  vomiting. 

A  case  of  this  character  came  under  the  care  of  the  writer  some 
years  ago,  and  the  gentleman  related  that  he  had  not  taken  a  meal  with 
his  family,  for  this  reason,  and  on  account  of  the  fetid  odor  of  his 
breath,  for  more  than  six  years. 

The  teeth  of  the  affected  side  are  often  sore  and  painful  to  percus- 
sion, even  though  they  may  not  be  factors  in  the  production  of  the 
disease  This  is  a  point  that  should  be  borne  in  mind  when  conduct- 
ing an  examination  in  a  case  of  this  character.  When  the  disease  is 
due  to  lesions  of  the  teeth,  the  affected  ones  are  usually  more  sensitive 
and  painful  to  the  percussion  test  than  are  those  adjacent  to  them;  yet 
in  exceptional  cases  the  most  careful  examination  may  fail  to  detect  a 
special  tenderness  in  any  of  the  teeth. 

Biagnosis.— The  diagnostic  signs  are,  the  location  and  the  char- 
acter of  the  pain,  unilateral  discharge  from  the  nose  (except  where  both 
antra  are  affected,  when  it  would  be  in  all  probability  bilateral),  swell- 
ing of  the  face,  bulging  of  the  diseased  side  of  the  vault  of  the  mouth 
tenderness  of  the  affected  side  of  the  face,  crepitation  over  the  thinned 
walls  of  the  antrum,  frequently  the  presence  of  diseased  teeth,  soreness 
of  the  teeth  to  percussion,  protrusion  of  the  eyeball,  fetor  of  the  breath, 
nausea  or  vomiting  on  rising  in  the  morning. 

These  conditions  are  not  always  well  marked  in  every  case,  but  a 
sufficient  number  will  be  present  in  a  majority  of  them  to  establish  a 

diagnosis. 

Differential  Diagnosis.— The  diseases  of  the  maxillary  sinus 
which  mav  be  confounded  with  abscess  or  suppuration  of  this  sinus 
are  angiomata,  malignant  neoplasms,  and  bony  tumors.  Tumors  of  the 
antrum  can  be  verv  positively  diagnosed  from  suppuration  and  mucous 


376  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

engorgements  by  means  of  the  electric  mouth-lamp  or  stomatoscope. 
The  patient  being  seated  in  a  dark  room,  the  lamp  is  placed  in  the 
mouth,  and  the  lips  closed  over  it,  when,  if  the  tissues  are  in  a  normal 
condition,  the  light  will  be  quite  readily  transmitted  through  the  cheeks 
and  lower  eyelids.  If  the  antrum  is  filled  with  fluid,  like  pus  or  heavy 
mucus,  the  light  is  somewhat  impeded,  while  if  it  be  filled  with  a  solid 
tumor  it  is  entirely  obstructed.  An  exploratory  puncture  or  incision 
with  the  exploring  needle  or  small  scalpel  will  often  immediately  clear 
up  the  diagnosis. 

Prognosis. — The  prognosis  is  usually  favorable,  except  in  those 
cases  in  which  the  discharges  have  burrowed  into  the  cranial  cavity. 
In  a  majority  of  cases  a  cure  is  effected  by  slow  degrees,  sometimes 
requiring  months,  and  even  one  or  two  years,  to  accomplish  it.  The 
general  condition  of  the  patient  is  an  important  factor  in  the  prognosis. 
A  tubercular  or  scrofulous  diathesis,  or  a  generally  debilitated  condi- 
tion, militates  against  a  rapid  cure.  In  persons  of  otherwise  good 
health  a  cure  is  sometimes  effected  in  a  few  weeks;  the  majority,  how- 
ever, extend  over  a  much  longer  period. 

Treatment. — For  the  successful  treatment  of  suppuration  or  ab- 
scess of  the  maxillary  sinus,  three  conditions  must  always  be  secured, 
viz:  First,  the  removal  of  the  exciting  cause;  second,  the  complete 
evacuation  of  the  contents  of  the  sinus;  and,  third,  the  establishment  of 
perfect  drainage. 

Failure  to  secure  these  conditions  is  among  the  principal  reasons 
why  the  treatment  of  this  disease  is  many  times  so  unsatisfactory.  In 
order  to  secure  these  conditions  the  sinus  should  be  opened  at  its  most 
dependent  point,  which  is  at  the  floor  of  the  cavity  opposite  the  alve- 
olus of  the  second  molar  tooth,  and  if  bony  septa  are  present,  these 
should  be  broken  down  with  the  curette  or  surgical  bur.  The  simplest 
way  of  entering  the  antrum  is  by  extracting  the  first  or  second  molar 
tooth,  and  enlarging  and  deepening  the  alveolus  of  the  anterior  buccal 
root.  This  alveolus  is  selected  because  it  carries  a  larger  root  than  the 
posterior  one,  hence  is  more  available  for  this  purpose.  If  these  teeth 
are  sound,  it  is  preferable  to  make  an  opening  between  the  posterior 
buccal  root  of  the  first  molar  and  the  anterior  root  of  the  second, 
as  suggested  by  Heath,  rather  than  to  needlessly  sacrifice  sound  teeth. 
On  the  other  hand,  all  diseased  teeth  and  roots  upon  the  affected  side 
should  be  extracted  at  once,  as  they  are  more  than  likely  to  be  the  pri- 
mary cause  of  the  disease;  and  if  they  should  not  be  directly  respon- 
sible, they  are  usually  a  source  of  irritation,  and  may  therefore  become 
a  secondary  cause  of  the  lesion. 

In  opening  the  antrum,  the  ordinary  trocar  fitted  with  a  canula  is 
a  very  satisfactory  instrument  if  properly  handled.  There  is  danger, 
however,  when  the  bone  is  thick  and  hard,  requiring  a  considerable 


DISEASES    OF   THE    MAXILLARY    SINUS.  377 

amount  of  pressure  to  penetrate  it,  that  it  may  suddenly  break  through, 
and  the  point  of  the  trocar  penetrate  the  floor  of  the  orbit.  This  acci- 
dent may  be  guarded  against  by  so  holding  the  instrument  that  it  can 
only  penetrate  to  the  desired  depth,  or  an  adjustable  metal  guard  can 
be  placed  upon  the  instrument,  which  will  effectually  prevent  its  going 
beyond  the  depth  to  which  it  is  desired  to  penetrate.  The  trocar,  Fig. 
143.  was  devised  by  the  writer  expressly  for  this  purpose.  The  guard 
is  fitted  into  the  handle  by  means  of  a  screw,  which  makes  it  possible 
to  penetrate  the  antrum  to  any  desired  depth,  while  the  handle  is  fitted 
with  a  device  operated  by  the  thumb  which  carries  the  canula  forward 
to  the  tip  of  the  trocar,  and  allows  the  trocar  to  be  withdrawn,  leaving 
the  canula  in  position. 

The  most  satisfactory  method  of  opening  the  antrum  is  by  the  use 
of  a  spear-pointed  drill,  revolved  by  the  surgical  engine.  With  this 
instrument  the  surgeon  can  feel  his  way  through  the  bone  so  delicately 

Fig.  143. 


Author's  Antrum  Trucar  with  Guard.     (Reduced.) 

and  surely  that  he  can  tell  when  the  drill  is  about  to  enter  the  cavity, 
and  even  when  it  pierces  the  mucous  membrane,  so  that  by  this  method 
accidents  are  reduced  to  the  minimum.  In  order  to  secure  free  dis- 
charge, the  drill  should  leave  an  opening  at  least  one-fourth  of  an  inch 
in  diameter.  This  is  about  as  large  an  opening  as  can  be  secured  be- 
tween the  roots  of  the  first  and  second  molars  without  injuring  the 
roots  of  these  teeth;  but  when  the  opening  is  made  through  the  alve- 
olus there  is  no  reason  why  it  may  not  with  advantage  be  made  larger. 
When  the  probe  reveals  the  presence  of  bony  septa,  it  becomes  neces- 
sary to  make  the  opening  somewhat  larger.  Under  such  circum- 
stances, the  septum  of  bone  between  the  anterior  and  posterior  buccal 
alveoli  can  be  cut  through  with  a  long  side-cutting  bur,  which  is  an 
enlargement  in  shape  of  the  dentist's  fissure  bur.  (See  Fig.  125.) 
This  will  give  entrance  to  a  small  spoon  curette,  or  the  round  surgical 
bur,  with  which  to  break  down  the  bony  septa. 

An  opening  which  is  made  through  the  external  wall  of  the  an- 
trum between  the  roots  of  the  first  and  second  molars  is  preferable  to 
one  made  through  the  alveolus  of  a  tooth,  for  the  reason  that  in  the 
former  case  the  cheek,  falling  over  the  opening  made  through  the  ex- 
ternal wall,  is  a  protection  against  the  entrance  of  food,' while  in  the 
latter,  unless  it  is  kept  plugged,  foreign  substances  constantly  enter, 
which,  acting  as  irritants,  tend  to  keep  up  the  inflammatory  symptoms. 


378  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

Plugs  and  drainage-tubes  are  a  source  of  great  annoyance  and 
inconvenience  to  the  patient,  and,  in  the  opinion  of  the  writer,  are 
many  times  a  source  of  irritation,  thus  retarding  the  progress  of  the 
cure.  When  the  opening  is  through  the  alveolus  of  a  tooth,  plugs  or 
tubes  with  stoppers  are  necessary  to  prevent  the  ingress  of  food;  at  the 
same  time  they  prevent  the  free  discharge  of  the  secretions.  This 
condition,  in  relation  to  an  abscess  in  any  other  location  of  the  body, 
would  not  be  tolerated  by  an  enlightened  surgeon  for  a  moment,  as 
it  would  defeat  the  very  object  for  which  drainage  was  established. 
The  preference,  therefore,  should  be  given,  when  circumstances  will 
permit,  to  that  operation  for  opening  the  antrum  which  will  not  require 
the  use  of  plugs  or  tubes  in  the  after-treatment.  When  a  drainage- 
tube  is  employed,  no  better  form  can  be  chosen  than  that  suggested  by 
Talbot,  Fig.  144. 

Fig.  144. 


Talbot's  Antru.m  Tube.     (After  Talbot.) 

Some  surgeons  prefer  the  method  of  opening  the  antrum  through 
the  nose,  as  near  to  the  natural  entrance  as  possible,  one  purpose  of 
which  is  to  render  it  impossible  for  infection  to  occur  through  the 
mouth,  as  is  feared  if  an  opening  is  made  into  the  antrum  through  this 
cavity.  This  method  seems  to  be  open  to  several  important  objec- 
tions, on  account  of  the  difficulties  in  the  way  if  it  becomes  neces- 
sary to  break  down  bony  septa,  or  to  curette  the  surfaces  of  the  sinus. 
This  method,  however,  has  its  advantages  in  the  treatment  of  mucous 
engorgements,  for  all  that  is  necessary  in  these  cases  is  to  re-estab- 
lish the  discharge  of  the  secretions  into  the  nose;  but  in  those  more 
serious  conditions,  like  abscess  of  the  antrum,  from  various  causes,, 
entrance  through  the  mouth  is  to  be  preferred,  because  an  opening  can 
be  made  as  large  as  the  circumstances  require, — large  enough  to  admit 
the  index  finger,  or  larger,  as  sometimes  becomes  necessary,  especially 
where  septa  are  to  be  broken  down,  or  search  made  for  foreign  bodies 


niSITASliS    OF   THE    MAXILLARY    SINUS.  379 

or  malposed  teeth.  Under-  circumstances  like  these,  the  tactile  sensa- 
tion of  the  finger  is  a  much  surer  guide  to  a  correct  understanding  of 
existing  conditions  than  a  probe  or  a  sound,  which  are  the  only  means 
of  detecting  these  conditions  when  entering  the  antrum  through  the 
nose. 

General  anesthetics  are  frequently  necessary  in  operations  for 
opening  the  antrum,  especially  in  those  cases  requiring  the  extraction 
of  teeth,  the  cutting  of  bone  to  any  considerable  extent,  or  curetting 
the  mucous  membrane.  In  those  cases  requiring  only  the  puncture 
of  a  thin  wall  of  bone,  the  local  application  ,of  cocain  by  hypodermic 
injection  will  answer  a  good  purpose.  The  writer  has  made  several 
quite  extensive  operations  upon  the  floor  of  the  antrum  with  no  other 
anesthetic  than  cocain;  yet  he  feels  safer  with  ether  or  chloroform 
than  with  cocain,  and  therefore  does  not  recommend  its  use  when  re- 
peated injections  would  be  necessary  to  maintain  the  condition  of  local 
insensibility,  for  fear  of  establishing  the  toxic  symptoms  of  the  drug. 
Solutions  of  cocain  of  a  greater  strength  than  2  to  4  per  cent,  are  never 
required  in  these  operations. 

After  an  opening  has  been  made  into  the  antrum,  it  should  be 
thoroughly  irrigated  with  some  bland,  non-irritating  antiseptic  solution. 
The  writer  prefers  the  Thiersch  solution,  or  the  boric  acid  solution. 
Irrigation  should  be  continued  until  the  fluid  runs  clear.  The  ordi- 
nary irrigating  bag,  with  rubber  tubing  and  a  glass  nozzle,  is  preferable 
to  any  of  the  syringes  recommended  for  this  purpose. 

Solutions  of  bichlorid  of  mercury  and  carbolic  acid  have  certain 
disadvantages  which  should  cause  them  to  be  discarded  in  all  diseases 
of  the  mucous  membrane.  The  bichlorid  of  mercury  solutions  are 
more  or  less  irritating  to  all  mucous  surfaces,  if  of  a  strength  sufficient 
to  be  of  real  value  as  a  germicide,  and  have  the  added  disadvantage  of 
being  readily  absorbed  in  sufficient  quantities  to  produce  toxic  symp- 
toms, if  by  chance  the  fluid  should  be  retained  in  the  sinus.  Carbolic 
acid  is  also  irritating  to  mucous  surfaces  when  of  a  strength  to  be  val- 
uable for  antiseptic  purposes.  A  solution  of  less  than  5  per  cent,  would 
be  of  little  value  as  a  germicide,  while  one  of  that  strength  would  be 
irritating. 

The  employment  of  irritating  solutions  is,  in  the  mind  of  the 
writer,  another  reason  why  the  inflammatory  conditions  of  the  max- 
illary sinus  are  so  tedious  and  difficult  to  cure.  This  opinion  has 
grown  out  of  a  considerable  experience  in  the  treatment  of  this  class 
of  diseases,  and  experimenting  with  the  various  methods  of  treatment 
with  drugs  suggested  by  the  recognized  authorities  on  this  subject. 

The  peroxid  of  hydrogen,  and  medicinal  pyrozone,' are  remedies 
which  the  writer  has  lost  confidence  in  for  this  purpose, — not  that  they 
are  not  good  scavengers  or  good  disinfectants,  but  that  they  frequently 


380  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

cause  great  pain  and  irritation,  even  when  diluted,  from  the  rapid 
evolution  of  oxygen  gas,  and  the  consequent  pressure  upon  a  highly 
sensitive  membrane  when  they  are  injected  into  the  antrum,  especially 
in  those  cases  where  the  opening  made  for  evacuation  and  drainage  is 
necessarily  small. 

In  the  after-treatment  the  same  bland  solutions,  or  sterilized  water 
alone,  are  to  be  preferred  to  solutions  which  are  in  the  least  irritating 
or  over-stimulating.  Irrigation  should  be  performed  three  or  four 
times  per  diem  for  the  first  few  days  after  the  operation,  preferably  after 
meals  and  on  rising  in  the  morning.  As  the  symptoms  subside, 
irrigation  may  be  gradually  decreased  to  once  per  diem,  and  finally 
withdrawn  altogether. 

Insufflation  with  powders  is  not  to  be  recommended,  for  the 
reason  that  there  is  no  assurance  that  they  are  invariably  dissolved  in 
the  secretions.  Materials  of  this  character,  if  left  undissolved  in  the 
antrum,  would  be  likely  to  act  as  foreign  bodies,  thus  continuing  the 
irritation  and  preventing  a  cure. 

No  anxiety  need  be  felt  in  reference  to  the  final  closing  of  the 
opening  made  into  the  antrum.  There  is  more  difficulty  experienced, 
as  a  rule,  in  keeping  it  open  for  a  sufficient  length  of  time  for  proper 
treatment,  except  in  those  cases  where  plugs  or  tubes  are  used.  In 
exceptional  cases,  where  large  openings  have  been  made,  or  plugs  and 
tubes  have  been  used,  it  may  become  necessary  to  stimulate  granulation 
by  touching  the  edges  of  the  opening  with  nitrate  of  silver  or  the 
galvano-cautery,  followed  by  repeated  applications  of  tincture  of 
iodin,  or  it  may  be  closed  by  a  plastic  operation. 

The  treatment  of  mucous  engorgements  is  less  difficult,  from  the 
curative  standpoint,  than  suppurative  conditions  of  the  antrum,  except 
in  those  cases  where  the  secretions  have  been  retained  for  a  period 
sufficiently  long  for  decomposition  to  have  taken  place,  when  the  in- 
flammatory condition  assumes  a  chronic  type,  rendering  the  treatment 
much  more  difficult  and  tedious. 

In  the  ordinary  cases  of  mucous  engorgement  of  the  antrum  re- 
sulting from  acute  coryza,  or  la  grippe,  drainage  can  be  secured  by 
expanding  the  natural  opening  into  the  nose.  This  may  be  accom- 
plished by  passing  probes  or  sounds  of  gradually-increasing  diameter. 
To  avoid  the  paroxysms  of  sneezing,  and  the  pain  induced  by  the  intro- 
duction of  the  probe,  the  mucous  membrane  should  be  sprayed  with  a 
10  per  cent,  solution  of  cocain.  When  the  natural  opening  cannot  be 
found, — and  it  is  not  always  an  easy  matter  to  find  it  and  introduce  the 
probe, — the  sinus  can  be  entered  at  one  of  those  points  already  indi- 
cated for  draining  this  cavity,  preferably  between  the  roots  of  the  first 
and  second  molar  teeth. 

In  the  experience  of  the  writer,  this  simple  form  of  antral  disease 


DISEASES    OF    THE    MAXILLARY    SINUS.  381 

is  the  most  amenable  to  treatment;  thorough  drainage  alone  being  all 
that  has  been  required  in  many  cases  to  effect  a  complete  and  perma- 
nent cure  in  from  two  to  three  weeks.  In  the  more  persistent  cases, 
daily  irrigation  with  the  nasal  douche,  charged  with  sterilized  water  or 
some  of  the  bland  antiseptic  solutions,  will  be  necessary.  If  a  purulent 
condition  of  the  secretions  should  follow  the  opening  of  the  antrum, 
it  is  certain  that  the  condition  first  mentioned  has  not  been  secured; 
upon  a  more  careful  examination  it  will  be  discovered  that  either  com- 
plete evacuation  has  not  been  secured  on  account  of  dividing  septa,  or 
not  having  punctured  the  cavity  at  its  most  dependent  point ;  or  that  the 
drainage  is  imperfect,  either  from  the  closure  of  the  opening  in  the 
mucous  membrane,  the  formation  of  a  clot  in  the  wound,  or  the  en- 
trance of  foreign  substances  or  septic  bacteria.  It  is  often  difficult  to 
maintain  a  free  opening  in  the  mucous  lining  of  the  cavity  by  the  ordi- 
nary methods,  as  the  tendency  of  wounds  in  this  tissue  is  to  heal  very 
quickly.  To  obviate  this  dif^culty,  the  sides  of  the  opening  may  be 
cauterized  with  the  electro-thermal  cautery;  two  or  three  applications 
may  be  necessary  to  secure  an  opening  that  will  remain  patulous  for  a 
sufficiently  long  period  to  accomplish  a  cure. 


CHAPTER    XXXVIII. 
DISEASES  OF  THE  MAXILLARY  SINUS  (Continued). 

Syphilitic  Ulceration  of  the  Antrum  of  Highmore. — This  is 
a  condition  of  rare  occurrence.  The  antrum,  however,  sometimes 
becomes  involved  when  the  roof  of  the  mouth  is  the  seat  of  the  destruc- 
tive syphilitic  process,  or  when  the  turbinated  bones  and  the  nasal  wall 
of  the  antrum  are  affected. 

This  manifestation  of  a  syphilitic  infection  is  generally  the  result  of 
the  tertiary  form  of  the  disease,  and  is  usually  an  extension  of  the  af- 
fection from  the  nasal  fossa.  The  writer  is  of  the  opinion  that  syphil- 
itic ulceration  of  the  mucous  lining  of  the  antrum  is  never  found  except 
as  a  tertiary  manifestation  and  an  extension  of  the  disease  already 
located  in  contiguous  parts,  although  he  is  fully  aware  that  in  giving 
expression  to  this  opinion  he  places  himself  in  opposition  to  the  views 
of  some  excellent  observers.  In  support  of  this  position,  reference  is 
made  to  Morrow,  who  says,  "Familiar  sequelae  of  tertiary  syphilis  are 
perforation  of  the  cartilaginous  and  bony  septum,  and  the  palatine  roof; 
caries  and  necrosis  of  bone,  ozena,  and  extension  of  the  disease  to  the 
antrum,  and  other  accessory  cavities,  and  to  the  bones  of  the  face  and 
skull." 

Garretson  says,  after  a  careful  examination  of  the  syphilitic  pa- 
tients in  Blockley  Hospital,  Philadelphia,  extending  over  a  whole  year, 
he  could  not  find  a  single  case  of  syphilitic  disease  of  the  antrum  in 
which  the  disease  had  its  origin  in  this  sinus. 

The  manifestations  of  syphilis  are  quite  common  in  the  nasal  cav- 
ity, but  they  belong  essentially  to  the  tertiary  stage,  the  earlier  symp- 
toms being  very  rarely  manifested  in  this  region. 

Bosworth  does  not  believe  the  secondary  stage  of  the  disease,  in 
the  form  of  mucous  patches,  ever  appears  in  the  nose. 

It  is  more  than  likely  that  such  secondary  manifestations  of  the 
disease  are  never  found  in  the  antrum  of  Highmore;  though  positive  or 
negative  demonstration  of  this  statement  could  not  be  furnished  except 
by  a  long  and  careful  search  for  the  proof  upon  persons  who  had  died 
while  suffering  from  secondary  lesions  of  the  disease.  Such  exami- 
nations may  have  been  made  and  the  results  published,  but  the  writer 
does  not  recall  any  published  account  of  such  a  line  of  investigation. 
382 


DISKASRS    OF    THE    MAXILLARY    SINUS.  383 

It  is  fair,  however,  under  the  circumstances,  to  reason  from  anal- 
ogy, that  inasmuch  as  the  same  type  of  mucous  membrane  Hnes  the 
maxillary  sinus  that  lines  the  nasal  passages,  and  that  the  secondary 
lesions  of  the  disease  are  very  rarely  if  ever  found  in  the  nasal  passages, 
the  same  immunity  in  all  probability  is  possessed  by  the  antral  lining 
membrane.  The  tertiary  manifestations  of  syphilis  in  the  nose  and 
antrum  usually  develop  in  from  five  to  fifteen  years  after  the  initial 
lesion,  or  the  primary  stage  of  the  disease,  in  the  formation  of  deep- 
seated  ulcerations  of  a  grave  and  destructive  character,  pursuing  a  rapid 
course,  causing  a  more  or  less  extensive  destruction  of  tissues,  and 
involving  the  cartilages  and  the  nasal  and  turbinated  bones  to  such  an 
extent  as  to  cause  most  horrible  deformities.  The  disease  is  character- 
ized bv  suppuration  and  necrosis,  accompanied  by  the  discharge  of 
masses  of  pus,  blood,  and  necrotic  tissue,  and  a  most  intolerably  fetid 
and  penetrating  odor  which  makes  the  patient  an  offense  to  himself 
and  to  every  one  who  comes  near  him. 

There  are  two  varieties  of  syphilitic  ulceration  of  the  nose  in  the 
tertiary  form  of  the  disease,  viz:  superficial  ulcer,  and  deep-seated 
ulcer. 

The  superficial  ulcer  is  usually  found  upon  the  mucous  membrane 
covering  the  cartilaginous  septum.  It  may  destroy  the  cartilaginous 
septum  and  then  attack  the  bony  septum,  resulting  in  a  more  or  less 
complete  destruction  of  this  portion  of  the  nose,  though  it  rarely  ex- 
tends so  far,  being  confined  generally  to  the  cartilaginous  septum. 

The  deep-seated  ulcer  is  by  far  the  most  serious  and  destructive 
form  of  tertiary  syphilis  found  in  the  nasal  cavity.  It  is  due  to  the  for- 
mation of  gummata  in  the  deeper  layers  of  the  mucous  membrane, 
which  later  become  softened  and  break  down,  developing  an  ulcerative 
action  of  a  rapid  and  destructive  type. 

This  form  of  ulceration  is  usually  found  upon  the  turbinated  bones, 
and  is'  characterized  by  deep  excavating  ulcers  with  ragged,  overhang- 
ing edges ;  the  surface  of  the  ulcer  is  bathed  wdth  yellow  pus  mingled 
wdth  fragments  of  blackened  gangrenous  tissue;  and  the  surrounding 
mucous  membrane  is  highly  congested,  often  turgid  and  purplish  in 

color. 

The  ulcerative  process  rapidly  penetrates  to  the  periosteum  and 
the  bone,  also  extending  laterally  wath  equal  rapidity,  often  causing 
extensive  necrosis  and  exfoliation  of  the  osseous  structures  of  the  nose, 
and  sometimes  involves  the  accessory  sinuses. 

There  is  always  an  offensive  discharge,  giving  the  odor  of  decom- 
posing pus  and  dead  bone,  accompanying  the  disease,  which  makes  the 
presence  of  these  poor  unfortunates  almost  intolerable.  The  tendency 
to  the  formation  of  crusts  or  masses  of  dried  pus,  mucus,  blood,  and 
gangrenous  tissue,  which  adhere  closely  to  the  surface,  and  are  exceed- 


384  SURGERY    or    THE    FACE,    MOUTH,    AND    JAWS. 

ingly  difficult  to  dislodge,  is  another  characteristic  of  the  disease.  These 
masses  when  expelled  are  in  odor  and  appearance  most  disgusting  and 
nauseating.  As  the  disease  progresses,  the  nasal  wall  of  the  antrum 
may  become  involved  in  the  destructive  process,  which  may  finally 
extend  to  the  mucous  membrane  lining  this  cavity.  When  the  antrum 
becomes  involved  there  is  usually  as  an  indication  a  swelling  at  the 
angle  of  the  nose  and  cheek,  and  in  those  cases  where  the  nasal  wall  of 
the  sinus  has  been  lost  by  necrosis,  this  fact  may  be  ascertained  by 
exploration  with  a  probe. 

Diagnosis. — There  are  no  characteristic  symptoms  of  the  disease 
located  in  the  antrum,  other  than  the  swelling  at  the  angle  of  the  nose 
and  cheek,  that  are  distinguishable  from  those  found  in  the  nose. 

The  more  common  location  of  the  disease  in  the  superior  maxillary 
bones  is  the  floor  of  the  nasal  fossa,  which  may  be  destroyed,  leaving  a 
more  or  less  extensive  opening  between  the  nose  and  mouth,  making 
the  swallowing  of  food  and  liquids  difficult,  and  greatly  impairing  the 
voice. 

The  tertiary  form  of  the  disease  rarely  involves  the  velum  palati, 
the  septum  alae  narium,  or  the  cutaneous  surfaces,  but  is  usually  con- 
fined to  the  cartilaginous  septum,  the  inner  nasal  bones,  the  turbinated 
bones,  and  the  superior  maxilla. 

The  deformities  which  result  are  the  falling  in  of  the  nose  caused 
by  the  loss  of  its  bony  supports,  and  the  perforation  of  the  hard  palate 
just  referred  to. 

One  case  only  has  the  writer  seen  of  syphilitic  ulceration  of  the 
antrum,  which  did  not  have  its  starting  point  in  the  nasal  fossa.  The 
patient  was  a  man  who  had  been  inoculated  twenty  years  before.  The 
disease  began  as  an  ulceration  of  the  mucous  membrane  covering  the 
hard  palate  opposite  the  right  second  molar  tooth,  resulting  in  perfora- 
tion of  the  hard  palate  and  antrum,  with  loss  of  the  entire  floor  of  the 
sinus,  together  with  the  teeth,  from  necrosis.  Figs.  145  and  146  are 
illustrations  of  the  secondary  form  of  the  disease  which  had  their  com- 
mencement in  the  velum  palati  in  the  form  of  ulcers,  and  later  involved 
the  palate  bones.  In  Fig.  145  the  opening  originally  extended  consid- 
erably farther  forward,  but  this  has  been  gradually  filled  up  by  the  pro- 
cess of  granulation. 

Differential  Diagnosis. — Syphilis  of  the  nose  and  antrum  is  often 
diagnosed  as  fetid  catarrh,  ozena,  and  other  forms  of  disease  which 
are  accompanied  by  foul-smelling  odor  and  discharges.  The  diagnosis, 
however,  is  rendered  quite  simple  if  a  good  view  of  the  nasal  cavity  can 
be  obtained  through  the  anterior  nares,  as  the  parts  most  likely  to  be 
afifected  are  generally  within  the  range  of  vision  through  these  open- 
ings. 

In  order  to  obtain  a  good  view  of  the  parts,  the  crusts  and  dis- 


DISEASES    OF   THE    MAXILLARY    SINUS. 


38: 


charges  must  first  be  removed,  as  these  cover  and  conceal  the  condi- 
tions of  the  tissues  beneath.     If  the  disease  is  fetid  catarrh  or  ozena, 

Fig.  145. 


Syphilitic  Ulceration  of  the  Velum  Palati  involving  the  Posterior  Border  of  the 

Palate  Bones. 


Fig.  146. 


Syphilitic  Ulceration  involving  Portions  of  the  Palate  Bones  and  the  Velum  Palati. 


the  mucous  membrane,  the  septum,  and  the  walls  of  the  nasal  cavity 
will  be  found  intact;  while  on  the  other  hand,  if  it  is  syphilis,  ulcera- 

26 


386  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

tions  upon  the  septum  or  turbinated  bones,  or  necrosis  of  bone  of 
greater  or  less  extent,  will  be  discovered. 

This  fact,  however,  must  be  borne  in  mind  in  making  a  diagnosis, 
viz:  that  ulceration  never  occurs  except  as  a  result  of  some  general 
dyscrasia  like  syphilis, tuberculosis,  cancer,  the  exanthemata,  etc.;  there 
is,  however,  no  danger  of  making  an  error  in  the  diagnosis,  for  differ- 
entiation is  made  comparatively  simple  by  the  presence  of  symptoms 
which  are  characteristic  of  one  or  the  other  of  the  diseases.  It  is  safe 
therefore  to  say  that  if  ulceration  be  found  without  any  of  the  general 
symptoms  of  impaired  health  which  accompany  tuberculosis,  cancer,  or 
the  exanthemata,  the  disease  is  in  all  probability  due  to  syphilis,  even 
though  no  positive  history  of  infection  with  the  syphilitic  virus  can  be 
established,  for  it  is  often  difficult  after  the  lapse  of  so  long  a  period  to 
arrive  at  a  definite  history  of  the  presence  of  the  primary  lesion  or  of 
secondary  manifestations. 

Treatment. — The  systemic  treatment  of  tertiary  syphilis  is  confined 
to  the  iodid  of  potassium  in  gradually  increasing  doses,  beginning 
with  10  to  15  grain  doses  three  times  per  day,  adding  three  grains  each 
day  until  the  toxic  manifestations  of  the  drug  appear,  when  a  marked 
imxprovement  in  the  symptoms  is  usually  observed.  Mercury  is  contra- 
indicated  in  this  form  of  the  disease.  It  is  well  occasionally  to  with- 
draw all  systemic  medication.  Tonics,  sea  air,  a  generous  diet  with 
wine  or  malt  liquors,  are  always  indicated,  and  occasionally  this  is  all 
that  is  necessary. 

The  local  treatment  of  syphilitic  ulceration  of  the  nose  and  antrum 
should  be  directed  to  securing  cleanliness  of  the  parts,  by  removing 
secretions,  crusts,  and  pieces  of  dead  bone  which  are  sources  of  irrita- 
tion, stimulating  ulceration  and  retarding  the  reparative  process. 

The  removal  of  the  crusts  is  greatly  facilitated  by  the  use  of  the 
post-nasal  syringe  and  the  douche  charged  with  antiseptic  solutions, — 
the  milder  forms,  like  the  Thiersch  and  the  boric  acid  solutions,  being 
preferable. 

When  the  antrum  is  involved,  this  cavity  can  usually  be  reached 
through  the  nose  by  means  of  a  curved  nozzle  attached  to  the  syringe 
or  douche. 

Boric  acid  solution  and  cinnamon  water,  equal  parts,  is  a  good 
disinfectant  and  deodorizer,  and  may  be  used  to  best  advantage  with  the 
atomizer. 

The  removal  of  dead  bone  should  be  accomplished  at  as  early  a 
period  as  possible,  but  the  writer  does  not  believe  it  is  the  part  of  a 
wise  conservatism  to  attempt  its  removal  until  separation  has  taken 
place. 

Necrosis  of  the  Walls  of  the  Maxillary  Sinus. — Necrosis  of  the 
walls  of  the  maxillary  sinus  is  a  diseased  condition  of  somewhat  com- 


DISEASES    OF   THE    MAXILLARY    SINUS.  387 

mon  occurrence,  for  the  reason  that  there  are  so  many  lesions,  either 
of  an  idiopathic,  traumatic,  or  specific  origin,  which  affect  this  part  of 
the  face  and  have  a  tendency  to  result  in  inflammatory  conditions  of  the 
bone,  and  finally  in  necrosis. 

Necrosis  of  the  walls  of  the  antrum  may  occur  as  the  result  of  peri- 
ostitis, induced  by  certain  diseases  of  the  teeth,  such  as  septic  perice- 
mentitis, or  alveolar  abscess;  local  arsenical  poisoning  caused  by  the 
escape  of  the  drug  into  the  surrounding  tissues  when  used  for  the  pur- 
pose of  devitalizing  the  tooth-pulp;  fractures  resulting  from  the  extrac- 
tion of  teeth  contiguous  to  the  antrum;  rupture  of  the  walls  of  the 
antrum  from  the  accumulation  of  pus  or  other  fluids  in  the  sinus;  gun- 
shot wounds  and  other  injuries  causing  crushing  and  comminution 
of  the  walls  of  the  antrum;  tuberculosis,  syphilis,  the  exanthemata,  and 
mercurial  and  phosphorus  poisoning. 

The  walls  of  the  antrum  most  often  found  necrosed  are  the  nasal 
wall,  caused  by  specific  disease  extending  from  the  nasal  fossa;  the 
superior  wall  or  orbital  plate  and  the  inferior  wall  or  floor  of  the  sinus, 
from  rupture  induced  by  accumulated  fluid.  The  floor  of  the  antrum  is 
also  quite  frequently  the  seat  of  necrosis  as  a  result  of  the  diseased  con- 
ditions of  the  teeth  already  mentioned,  and  from  surgical  violence  in 
extracting  the  teeth  of  this  locality.  More  rarely  the  anterior  and  pos- 
terior walls  become  necrosed  from  inflammatory  conditions  of  the  sinus 
and  from  traumatic  injuries. 

Symptoms. — The  symptoms  of  necrosis  of  the  walls  of  the  maxil- 
lary sinus  are  the  same  as  in  necrosis  located  in  other  portions  of  the 
body;  briefly:  a  history  of  a  previous  acute  inflammation,  with  great 
pain,  swelling,  and  discharge  of  thick  pus.  Present  conditions,  pain 
slight,  swelling  of  the  overlying  tissues,  discharge  of  offensive  smell- 
ing, purulent  pus,  numerous  sinuses,  and  denuded  bone,  which  may  be 
felt  with  a  probe  passed  through  the  sinuses.  Sinuses  which  lead  to 
dead  bone  always  present  a  granular  appearance  at  the  surface,  and 
have  a  tendency  to  bleed  on  being  touched. 

The  most  frequent  locations  of  the  sinuses  in  necrosis  of  the 
antrum  are  the  roof  of  the  mouth,  alveolar  ridge  and  external  integu- 
ment in  the  regions  of  the  inner  canthus  of  the  eye,  and  the  infraorbital 
foramen.  Ugly  scars  often  result  from  the  healing  of  these  sinuses 
when  located  in  the  latter  regions,  and  not  infrequently  cause  ectropion 
of  the  lower  eyelid. 

Treatment. — The  operative  treatment  does  not  differ  essentially 
from  that  for  the  same  conditions  in  other  locations,  except  that  every 
means  should  be  employed  to  prevent  the  formation  of  unsightly  scars 
upon  the  face.  A  word  of  caution  may  not  be  amiss  to  the  young 
practitioner  in  relation  to  the  proper  time  to  operate  for  the  removal  of 
dead  bone  in  the  region  of  the  face.     A  safe  rule  to  follow  is  not  to 


388  SURGERY    OF   THE    FACE,    MOUTH,   AND   JAWS. 

attempt  to  remove  the  necrosed  bone  until  separation  has  taken  place 
between  the  living  and  dead  portions.  Less  deformity,  in  the  judgment 
of  the  writer,  follows  such  procedure  than  when  an  operation  is  per- 
formed before  this  process  of  exfoliation  has  been  completed.  It  is 
wise  to  frequently  examine  the  sequestrum  to  ascertain  if  separation 
has  taken  place,  and  as  soon  as  this  can  be  demonstrated  it  should  be 
removed.  The  constitutional  treatment  must  be  directed  to  the  build- 
ing up  of  the  health  of  the  patient  and  controlling  the  tendencies  of 
peculiar  dyscrasia  or  constitutional  vice. 

A  case  at  present  under  treatment,  which  gave  the  writer  consider- 
able trouble  from  its  rapid  extension  until  the  real  nature  of  the  disease 
was  discovered,  may  be  used  as  an  illustration  upon  this  point.  The 
patient,  a  man  forty  years  old,  was  referred  to  the  writer  by  a  profes- 
sional friend.  At  the  time  he  was  first  seen  there  was  considerable 
swelling  of  the  right  side  of  the  face  below  the  malar  bone,  and  the 
teeth  and  external  plate  of  the  alveolar  process  had  been  removed 
between  the  right  central  incisor  and  the  first  molar  of  the  same  side. 
From  general  appearances,  tertiary  syphilis  was  suspected,  but  he  de- 
nied ever  having  contracted  the  disease,  and  his  word  was  taken  upon 
that  point,  and  only  general  tonics  administered.  At  the  end  of  ten  days 
the  disease  had  extended  upward  to  the  inferior  border  of  the  orbit  and 
to  the  nasal  bone,  and  backward,  involving  the  floor  of  the  antrum  and 
the  palate  process  to  the  median  line.  He  was  then  placed  upon  the 
iodid  of  potassium",  15  grs.  three  times  per  diem,  increasing  the  dose 
each  day  3  grs.  At  the  end  of  two  weeks  there  was  a  very  marked 
improvement  in  the  conditions,  the  swelling  was  less,  the  disease  had 
not  extended  beyond  the  limits  just  mentioned,  exfoliation  had  already 
begun,  and  the  case  bade  fair  to  make  a  good  recovery,  but  with  the 
loss  of  a  considerable  portion  of  the  superior  maxillary  bone.  It  is 
possible  that  this  might  have  been  prevented  had  the  iodid  been  admin- 
istered at  first,  as  would  have  been  done  but  for  the  positive  assurances 
of  the  patient.  The  wiser  plan  therefore,  in  all  doubtful  cases,  regard- 
less of  the  statements  of  the  patient,  be  they  never  so  positive,  is  to 
immediately  begin  a  course  of  anti-syphilitic  treatment. 


CHAPTER    XXXIX. 

CYSTIC  TUxMORS  OF  THE  MAXILLARY  SINUS. 

The  maxillary  sinus  is  not  infrequently  the  seat  of  various  forms 
of  cystic  and  solid  tumors,  but  their  presence  is  rarely  discovered  until 
they  have  obtained  a  considerable  size,  filling  the  sinus  and  expanding 
its  walls.  Attention  is  drawn  to  the  presence  of  solid  tumors  by  the 
swelling,  and  the  pain  which  usually  accompanies  the  formation  of 
these  growths  and  certain  forms  of  malignant  neoplasms.  Among  the 
cystomata  or  cystic  tumors  found  in  the  antrum  may  be  mentioned 
Mucous  Cysts  and  Polypi. 

Mucous  Cysts  of  the  Antrum,  the  hydrops  antri  or  dropsy  of  the 
antrum  of  the  old  writers,  is  a  disease  resulting  from  the  cystic  degen- 
eration of  the  glandular  follicles  which  are  very  numerous  over  the 
entire  mucous  membrane  lining  the  cavity.  The  disease  is  character- 
ized by  the  presence  of  a  dark  straw-colored,  glairy  fluid,  sometimes 
gelatinous,  and  of  the  consistence  of  egg  albumin,  frequently  contain- 
ing considerable  quantities  of  cholesterin  which  appear  in  the  form 
of  small  flakes,  floating  in  the  fluid.  The  accumulation  of  the  fluid  is 
slow,  which  causes  a  painless  enlargement  of  the  face  upon  the  affected 
side,  with  expansion  of  the  antrum  and  thinning  of  its  walls. 

The  disease  was  formerly  thought  to  be  caused  by  the  retention 
of  the  natural  secretions,  but  modern  research  has  proved  this  view  to 
be  incorrect.  The  retention  of  the.  natural  secretions  is  generally  the 
result  of  acute  inflammatory  conditions  of  the  mucous  membrane  of  the 
nose  which  have  extended  to  the  sinus,  and  produced  occlusion  of  the 
ostium  maxillare. 

In  cystic  degeneration  of  the  mucous  membrane  of  the  antrum 
there  is  frequently  an  aggregation  of  small  cysts  which  makes  the  treat- 
ment of  the  case  a  more  difficult  one  than  when  the  sinus  is  filled  with 
a  single  cyst.  In  some  cases  the  cyst  seems  to  be  developed  within  the 
bony  wall  of  the  antrum,  or  between  the  bone  and  the  periosteum,  and 
by  lateral  extension  fills  the  cavity  and  makes  it  possible  under  such 
circumstances  to  mistake  the  cavity  of  the  cyst,  when  it  is  opened,  for 
the  sinus  itself. 

Occasionally  serous  cysts  develop  at  the  roots  of  devitalized  teeth 
as  a  result  of  chronic  inflammation.     Heath  mentions  a  case  reported 

389 


390  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

by  Fischer  in  which  he  was  able  by  post-mortem  examination  to 
clearly  trace  such  a  cyst  which  occupied  the  entire  antrum,  but  had  no 
connection  whatever  with  its  walls,  and  was  attached  only  to  the  roots 
of  a  molar  tooth  by  its  pericementum. 

Cysts  of  this  character,  though  not  so  extensive  in  size,  are  fre- 
quently found  in  both  the  upper  and  lower  jaws;  at  least  this  has  been 
the  observation  and  experience  of  the  writer.  One  somewhat  similar 
case  to  that  mentioned  by  Heath,  occurring  in  his  private  practice,  may 
be  used  as  an  example  of  the  difficulties  sometimes  experienced  in  mak- 
ing a  correct  diagnosis.  Mrs.  O.,  thirty-five  years  of  age,  was  referred 
for  treatment  of  an  extensive  enlargement  of  the  right  side  of  the 
face  in  the  region  of  the  antrum,  and  extending  forward  to  the  ala 
of  the  nose.  There  was  some  difficulty  in  breathing  through  the  right 
nostril,  due  to  bulging  of  the  nasal  wall  of  the  antrum.  The  contour  of 
the  palate  was  normal.  On  examination  of  the  teeth,  it  was  found  that 
the  lateral  incisor  and  the  first  bicuspid  were  both  devitalized,  the  pulp- 
canals  of  each  having  been  filled  some  years  before.  Percussion  of 
these  teeth  elicited  tenderness  in  the  first  bicuspid,  but  not  in  the  lateral. 
The  swelling  of  the  face  had  been  noticed  for  more  than  a  year,  and  it 
was  slowly  increasing  in  size.  There  was  no  discharge  from  the  nose, 
and  no  sinus  leading  to  the  enlargement.  The  tumor  was  firm  and  un- 
yielding. These  symptoms  all  pointed  to  the  presence  of  a  solid  tumoi 
of  the  antrum.  As  a  more  positive  means  of  diagnosis  an  exploratory 
puncture  was  decided  upon,  and  inasmuch  as  the  first  bicuspid  tooth 
was  badly  decayed,  this  was  extracted  with  the  intention  of  puncturing 
the  floor  of  the  antrum  through  its  alveolus,  but  upon  removal  of  the 
tooth  an  ounce  or  more  of  a  thick,  tenacious,  straw-colored  fluid,  filled 
with  flakes  of  cholesterin,  escaped  into  the  mouth.  The  opening  was 
therefore  enlarged  with  a  surgical  bur,  and  the  surface  of  the  antrum 
curetted  under  the  local  anesthetic  effect  of  cocain.  The  wound  was 
afterward  kept  open  for  several  weeks,  the  antrum  irrigated  twice  per 
diem,  when  the  fullness  of  the  jaw  subsided  and  the  opening  in  the 
antrum  was  permitted  to  close. 

Six  months  later  the  patient  returned  with  a  recurrence  of  the 
disease,  and  the  extraction  of  the  lateral  incisor  was  advised  on  account 
of  the  location  of  the  swelling,  which  was  greatest  under  the  ala  of  the 
nose.  This  she  declined  to  have  done,  but  as  a  compromise,  submitted 
to  the  opening  of  the  root-canal.  In  this  way  the  cyst  was  reached, 
and  a  considerable  discharge  followed  of  a  fluid  similar  to  that  evacu- 
ated from  the  antrum.  The  wall  of  the  cyst  was  then  punctured  near 
the  apex  of  the  root  of  the  tooth,  and  a  further  discharge  followed. 

Injections  of  a  lo  per  cent,  solution  of  iodin  and  glycerol  were 
used  twice  a  week  for  a  month,  with  marked  improvement,  after  which 
the  opening  was  allowed  to  close  and  the  root  of  the  tooth  was  refilled. 


CYSTIC    TUMORS    OF   THE    MAXILLARY    SINUS.  39I 

A  few  weeks  later  the  patient  returned  again  with  the  face  much 
swollen.  At  no  time  did  she  complain  of  pain  except  during  the  treat- 
ments. This  time  the  lateral  incisor  was  extracted,  and  it  was  found 
that  a  large  cyst  had  been  formed  at  the  apex  of  the  root,  communicat- 
ing with  the  antrum.  A  counter-opening  was  made  into  the  sinus  at  a 
point  near  the  apex  of  the  alveolus  of  the  lost  first  bicuspid  tooth,  and 
the  cyst  and  antrum  were  curetted  and  then  irrigated  with  Thiersch 
solution.  Following  the  operation  there  was  a  slight  discharge  of  the 
typical  secretion  of  cystic  tumors  for  a  few  days,  when  it  ceased  alto- 
gether, and  the  openings  were  allowed  to  close.  At  the  end  of  five 
years  there  had  been  no  return  of  the  disease. 

Symptoms  and  Diagnosis. — The  disease  is  of  slow  and  painless 
growth,  the  very  antithesis  of  suppuration  or  empyema  of  the  antrum, 
which  is  rapid  and  painful  in  its  development.  Sooner  or  later  the 
cheek  becomes  prominent  and  rounded,  sometimes  considerably  en- 
larged; protrusion  of  the  eye  may  occur,  the  nose  is  forced  to  the  oppo- 
site side,  the  nasal  fossa  becomes  occluded  from  bulging  of  the  nasal 
wall  of  the  antrum,  and  sometimes  the  palate  is  depressed  to  such  an 
extent  as  to  interfere  with  deglutition.  The  tumor  may  be  soft  and 
elastic  in  some  places,  and  hard  and  resisting  at  others. 

Pressure  over  the  elastic  portions  gives  the  parchment-like  crepita- 
tion which  accompanies  bone  that  is  greatly  thinned  and  expanded. 
There  is  usually  no  discharge  from  the  nose.  In  many  respects  it 
closely  resembles  in  appearance  solid  tumors  of  the  jaws.  Errors  in 
diagnosis  on  this  account  have  been  frequently  made,  through  which 
even  excision  of  an  entire  jaw  has  been  performed,  and  the  mistake  not 
discovered  until  it  was  too  late  to  rectify  it.  The  conservative  sur- 
geon will  not  fail  to  take  the  precaution  of  an  exploratory  puncture 
or  incision  when  making  the  diagnosis  of  a  doubtful  tumor,  as  this  will 
give  him  positive  data  upon  which  to  base  his  opinion  so  far  as  the  gen- 
eral character  of  the  growth  is  concerned. 

■Prognosis. — The  disease  is  prone  to  recurrence  unless  the  treat- 
ment is  thorough  and  heroic.  The  deformity  of  the  face  which  has 
been  occasioned  by  the  expansion  of  the  bone  will  gradually  but  finally 
disappear  after  the  disease  has  been  cured. 

Treatment. — The  treatment  consists  of  the  evacuation  of  the  con- 
tents of  the  cyst  by  free  incision  at  its  most  dependent  portion,  curet- 
ting its  inner  surface,  irrigation  with  some  antiseptic  solution,  and 
stimulating  injections  to  promote  granulation.  In  those  cases  where 
the  distention  of  the  bone  has  been  considerable,  a  portion  of  the  exter- 
nal wall  should  be  removed,  or  crushed  in. 

Irrigation  and  the  stimulating  injections  should  not  be  discon- 
tinued until  all  tendency  to  the  formation  of  the  characteristic  discharge 
has  ceased. 


392  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

Polypus  of  the  Antrum. — A  polypus  is  a  small  pedunculated 
cystic  tumor  growing  from  a  mucous  surface. 

Polypi  of  the  antrum  are  similar  in  structure  to  those  found  asso- 
ciated with  the  mucous  membrane  of  the  nasal  passages.  There  are 
two  varieties,  the  fleshy  and  the  cystic.  They  are  the  result  of  hyper- 
trophies— inflammatory  hyperplasia — of  the  submucous  connective 
tissue  and  of  the  mucous  membrane. 

When  the  tumor  arises  from  the  submucous  layer  the  connective- 
tissue  elements  will  predominate  and  result  in  the  formation  of  a  fleshy 
polypus;  when  it  arises  from  the  mucous  membrane  proper,  the  glandu- 
lar structures  will  be  in  excess  and  a  cystic  form  will  be  produced.  An 
intermediate  form  is  sometimes  developed,  having  a  loose  fibrous  struc- 
ture with  glandular  elements,  resulting  in  the  formation  of  a  semi- 
gelatinous  polypus  which  very  closely  resembles  the  common  form  of 
polypus  of  the  nose.  Polypi  of  the  antrum  are  usually  very  vascular, 
and  cause  considerable  hemorrhage  when  they  are  surgically  interfered 
with. 

The  disease  is  not  a  common  one,  and  yet  far  more  frequent  than 
is  generally  supposed.  Luschka  in  his  investigations  found  that  out 
of  sixty  subjects  examined  by  him,  five  had  polypi  of  the  antrum,  or  one 
in  twelve. 

Symptoms  and  Diagnosis. — The  symptoms  do  not  differ  materially 
from  those  of  mucous  cysts  of  the  antrum. 

Polypi  may  be  present  in  the  antrum  for  years,  and  the  patient 
remain  entirely  unconscious  of  the  fact  until  by  their  size  they  cause 
absorption  of  the  nasal  wall  of  the  sinus  or  expansion  of  the  bone,  with 
external  deformity  of  the  face.  The  thin  nasal  wall  of  the  antrum  is  the 
one  which  most  frequently  gives  way  from  absorption,  induced  by  the 
pressure  of  the  cysts  which  occupy  this  cavity,  and  for  this  reason  it  is 
sometimes  difficult  to  determine  when  the  polypus  occupies  the  nasal 
fossa  also,  whether  it  originated  in  the  nose  or  in  the  antrum.  John 
Bell,  Syme,  Vidal  de  Cassis,  and  others,  have  maintained  that  polypus 
never  originated  in  the  antrum,  but  was  always  an  intrusion  from  the 
nose,  while  Paget,  Fergusson,  and  others  hold  the  opposite  view,  their 
opinions  being  based  upon  practical  demonstration  of  the  fact. 

It  would  seem,  therefore,  that  in  most  individuals  who  may  per- 
haps have  polypi  in  the  antrum,  the  growths  never  reach  a  size  to 
cause  any  inconvenience  or  deformity,  and  consequently  their  presence 
rem.ains  unsuspected. 

When  the  polypus  is  of  sufficient  size  to  have  intruded  into  the 
nasal  passages,  the  nostril  will  be  more  or  less  completely  occluded. 
Damp  weather  seems  to  cause  them  to  swell  and  more  completely  close 
the  nasal  passages. 

Prognosis. — The  prognosis  of  polypi  of  the  antrum  is  generally 


CYSTIC   TUMORS    OF   THE    MAXILLARY    SINUS.  393 

considered  very  good,  but  according  to  Heath  in  some  instances  they 
seem  to  have  a  mahgnant  character,  or  at  least  are  the  forerunners  of 
mahgnant  disease  in  the  antrum  and  jaw.  The  writer's  experience  has 
been  so  Hmited  in  this  particular  direction  that  he  does  not  feel  quali- 
fied to  hazard  an  opinion  upon  the  matter,  therefore  accepts  the  teach- 
ing of  the  eminent  authority  just  mentioned,  especially  as  polypus  of 
the  nose  in  certain  cases  seems  to  possess  a  tendency  to  malignant  de- 
generation. 

Treatment. — The  treatment  of  polypus  of  the  antrum,  if  it  suc- 
ceeds, must  be  somewhat  in  the  nature  of  a  radical  operation. 
Thorough  extirpation  of  the  growth,  either  through  the  nasal  wall,  the 
external  wall,  or  the  floor  of  the  antrum,  is  indicated. 

The  first  is  to  be  preferred  when  it  can  be  accomplished  in  the 
thorough  manner  necessary  for  a  cure,  as  it  does  not  require  an  incision 
through  the  external  tissue  of  the  face  nor  the  loss  of  several  teeth,  as 
would  be  the  case  if  the  sinus  was  to  be  reached,  on  the  one  hand 
through  the  cheek,  or  on  the  other  through  its  floor.  Considerable 
difficulty  is  sometimes  experienced  in  trying  to  remove  such  growth  in 
the  antrum  through  the  nostril,  but  with  polypus  forceps  properly 
curved,  and  a  goodly  allowance  of  skill  and  patience,  the  antrum  may 
be  reached  through  a  previously  made  opening  in  the  nasal  wall,  and 
explored  to  its  farthest  extremity.  There  is,  however,  an  element  of 
uncertainty  always  present  in  this  operation,  as  to  whether  the  growth 
has  been  entirely  removed  or  not. 

If  the  antrum  is  opened  through  the  external  wall  the  superior 
maxillary  bone  must  be  laid  bare,  by  laying  back  the  lip  and  cheek  as 
in  the  operation  for  exsection  of  this  bone,  and  the  wall  of  the  antrum 
penetrated  with  a  trephine,  chisel,  or  the  surgical  saw  or  bur. 

If  the  opening  is  made  through  the  floor  of  the  antrum,  two  or 
three  teeth  must  first  be  extracted,  and  afterward  the  bone  can  be  cut 
away  with  the  surgical  burs.  A  sufHciently  large  opening  must  be 
made  to  permit  exploration  with  the  index  finger. 

The  after-treatment  consists  of  the  usual  irrigation  of  the  sinus 
with  non-irritating  antiseptic  solutions,  until  the  tissues  of  the  antrum 
have  healed  and  the  external  wound  has  closed. 


CHAPTER    XL. 

DISEASES  OF  THE  SALIVARY  GLANDS. 

Inflammation  of  the  Parotid  G-land,  parotitis,  or  mumps,  is  a  spe- 
cific infectious  disease,  whicli  affects  one  or  both  parotid  glands.  Dr. 
]\Iichaelis  recently  discovered  the  microbe  of  mumps  to  be  a  strepto- 
coccus, similar  to  the  gonococcus  and  meningococcus.  It  occurs  most 
frequently  in  young  males,  and  most  commonly  during  the  period  of 
adolescence.  A  diphtheritic  form  of  the  disease  is  sometimes  observed, 
but  its  most  common  form  is  the  simple  inflammation  of  the  gland 
known  as  mumps.  The  disease  often  assumes  an  epidemic  character, 
and  spreads  throughout  schools  and  communities. 

Incubation  Period. — The  incubation  period  of  parotitis  varies  from 
fourteen  to  eighteen  days  for  young  subjects  and  from  eighteen  to 
twenty-four  days  for  adults.  The  duration  of  the  disease  varies  in 
children's  institutions  in  a  like  manner,  the  average  being  about 
eighteen  or  nineteen  days;  in  garrisons  the  average  is  twenty-one  to 
twenty-two  days.  Since  the  disease  is  not  contagious  after  its  full 
development,  isolation  for  a  period  of  fifteen  days  is  quite  sufficient. 
(Poinier.) 

Symptoms  and  Diagnosis. — The  affection  may  be  ushered  in  by  a 
rigor,  nausea,  elevation  of  temperature,  and  a  general  feeling  of  lassi- 
tude. In  a  day  or  two  there  is  dull  pain  at  the  back  of  the  jaw,  and 
considerable  local  swelling,  which  may  interfere  with  mastication  and 
deglutition.  In  the  milder  forms  of  the  disease  the  patient  only  com- 
plains of  slight  stiffness  of  the  jaws,  and  pain  when  masticating  food  or 
upon  taking  acids  into  the  mouth ;  while  the  constitutional  disturbances 
may  be  so  slight  as  to  escape  observation.  The  disease  may  appear 
first  upon  one  side,  then  upon  the  other,  or  both  sides  may  be  affected 
simultaneously.  One  attack  gives  immunity  for  the  future.  The 
pathology  of  the  disease  is  still  in  obscurity.  The  chief  danger  to  be 
apprehended  in  this  disease  is  metastasis  to  the  testes,  mammae,  and 
ovaries.  Happily  these  complications  are  rare.  In  about  three  per 
cent,  of  the  cases  metastasis  of  the  testes  occurs,  producing  a  true  or- 
chitis, which  is  rarely  found  as  a  primary  afifection  under  any  other  cir- 
cumstances. The  afifection  usually  terminates  by  resolution,  and  rarely 
ends  in  suppuration. 

391 


DISEASES   OF   THE    SALIVARY    GLANDS.  395 

Inflammation  and  suppuration  of  the  glands  is  sometimes  a  sequel 
of  typhoid  fever,  puerperal  fever,  and  erysipelas,  and  of  scarlet  fever  and 
variola  in  children ;  or  it  may  be  associated  with  pyemia.  Involvement 
of  the  neighboring  lymphatics  in  these  cases  is  to  be  expected.  Under 
such  circumstances  the  disease  is  attended  with  great  prostration,  high 
temperature,  and  delirium.     The  pus  coming  from  such  abscesses  is  of 

fetid  odor. 

Prognosis.— The  prognosis  in  the  latter  cases  is  very  grave  mdeed, 
for  if  the"  disease  is  left  to  itself  the  abscess  may  open  into  the  auditory 
meatus,  or,  as  an  exceptional  comphcation,  it  may  pass  downward  to 
the  chest,  or  extend  in  an  upward  direction  along  the  sheath  of  the 
carotid  artery  to  the  skull,  or  behind  the  pharynx,  or  upward  to  the 
temporo-maxillary  joint. 

Treatment.— In  the  milder  form  of  the  disease  the  only  treatment 
that  is  required  is  protection  from  taking  cold.  In  the  more  ordinary 
form,  absolute  rest  and  protection  from  sudden  change  of  temperature 
are  demanded.  If  the  temperature  runs  high,  this  should  be  controlled 
by  appropriate  remedies.  Dry  heat  applied  to  the  side  of  the  face  in 
the  form  of  heated  flannels,  a  hot  brick  wrapped  in  flannel,  or  a  rubber 
bag  filled  with  hot  water,  will  mitigate  the  pain.  Liquid  food  will  be 
required  for  a  few  days.  Medicines  beyond  a  saline  cathartic  and 
anodynes  are  rarely  needed.  Occasionally  the  attack  will  leave  the 
patient  in  a  debiHtated  condition  demanding  tonics.  In  the  more  seri- 
ous form  of  the  disease,  involving  suppuration  of  the  glands,  the  pus 
should  be  evacuated  as  soon  as  fluctuation  can  be  discovered,  and  the 
cavity  irrigated  with  bichlorid  of  mercury  solution,  i  to  2000,  drainage 
provided  for,  and  the  wound  dressed  antiseptically.  When  the  pus  is 
superficially  located,  it  is  best  to  make  the  incision  in  a  line  with  the 
course  of  the  facial  nerve,  so  as  to  avoid  the  possibility  of  producing 
paralysis  of  the  facial  muscles  by  severing  this  nerve.  If  a  deep  incis- 
ion is  necessary,  it  should  be  made  upon  the  line  and  in  front  of  the 
external  carotid  artery.  The  exhibition  of  quinin  and  iron,  with  nour- 
ishing food,  should  constitute  the  systemic  treatment,  and  in  cases 
accompanied  with  great  prostration  stimulants  should  be  freely  used. 

Salivary  Calculi.— A  salivary  calculus  is  a  calcareous  deposit  in  a 
salivary  gland  or  its  duct. 

These  concretions  occasionally  form  within  the  salivary  ducts,  and 
much  more  rarely  within  the  gland  itself.  Salivary  calculi  are  seldom 
found  within  the  parotid  gland  or  its  duct.  The  most  common  location 
of  these  concretions  is  in  the  duct  of  Wharton;  more  rarely  in  the  ducts 
of  the  sublingual  gland.  Calculi  of  the  submaxillary  and  sublingual 
glands  are  somewhat  rare,  but  the  greater  number  of  the  reported  cases 
have  been  found  associated  with  the  submaxillary  glands.  Fiitterer 
found  one  hundred  and  fifty-eight  cases  of  salivary  calculi  in  the  sub- 


396  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

maxillary  and  sublingual  glands  mentioned  in  medical  and  surgical 
literature,  but  he  could  only  secure  access  to  the  full  reports  of  sixty- 
seven  of  this  number.  Out  of  the  sixty-seven  cases,  he  found  nine  were 
located  in  the  submaxillary  gland  itself;  six  were  found  in  the  sublin- 
gual gland  or  its  ducts,  and  the  remainder — fifty-two — were  located  in 
the  duct  of  Wharton.  Six  cases  only  of  calculi  in  the  parotid  gland  or 
its  duct  were  found  in  this  search.  To  recapitulate:  Out  of  seventy- 
three  cases  of  salivary  calculi,  affecting  the  parotid,  submaxillary,  and 
sublingual  glands  and  their  ducts,  six  were  associated  with  the  parotid 
or  the  duct  of  Stenson;  nine  with  the  submaxillary  gland  alone;  six 
with  the  sublingual  gland  or  its  ducts,  and  fifty-two  with  the  duct  of 
Wharton. 

Salivary  calculi  are  seen  most  frequently  between  the  ages  of 
twenty  and  forty  years.  The  youngest  person  reported  in  the  cases 
gathered  by  Fiitterer  in  which  a  calculus  was  found,  was  twelve  years 
of  age,  and  the  oldest  was  seventy  years.  Burdel  reported  a  case  to  the 
French  Academy,  in  which  a  concretion  was  found  in  the  sublingual 
duct  of  an  infant  only  three  weeks  old.  This  calculus  was  about  the 
size  of  a  grain  of  wheat,  yellow  in  color,  its  surface  granular,  wrinkled, 
and  apparently  formed  of  minute  cones  cemented  together  at  their 
base.  The  analysis  showed  it  to  be  composed  almost  entirely  of  cal- 
cium phosphate,  and  a  small  proportion  of  nitrogenous  organic  matter. 
This  no  doubt  was  a  concretion  of  pre-natal  formation. 

Causes. — ^The  causes  of  salivary  calculus  may  be  the  presence  of  a 
foreign  substance  lodged  in  the  duct,  or  bacteria,  most  likely  the 
Leptothrix  huccalis.  Fiitterer  was  unable  to  demonstrate  leptothrix, 
but  he  still  argues  that  they  are  the  most  likely  nidus  around  which  the 
deposit  is  formed.  The  presence  of  a  foreign  substance  in  the  center 
of  the  calculus  has  been  demonstrated  in  a  few  cases;  but  in  the  great 
majority  no  such  evidence  could  be  found.  There  seems  to  be  a  close 
connection  between  the  formation  of  calculi  in  the  salivary  glands  and 
the  formation  of  calculus  upon  the  teeth,  as  persons  with  salivary  cal- 
culi of  the  glands  usually  have  considerable  calcareous  deposits  upon 
the  teeth.  Richet  first  called  attention  to  this  fact.  It  has  been  the 
general  impression  among  English  surgeons  that  these  deposits  in  the 
salivary  glands  were  closely  connected  with  the  gouty  diathesis. 

It  has  been  generally  stated  that  these  calculi  were  composed  prin- 
cipally of  calcium  carbonate  and  phosphate,  and  magnesium  phosphate. 
Fiitterer  has  examined  several  specimens,  and  finds  calcium  phosphate 
largely  in  excess  of  the  carbonate.  Garretson  reports  the  examination 
of  a  calculus  taken  from  the  duct  of  Wharton,  which  showed  the  same 
composition.  Ptyalin,  xanthin,  and  uric  acid  were  also  found  in  them 
by  Fiitterer,  which  would  seem  to  prove  the  connection  of  the  forma- 
tion of  these  concretions  with  the  gouty  diathesis.     The  specific  gravity 


DISEASES    OF    THE    SALIVARY    GLANDS.  397 

of  the  calculi  in  the  reported  cases  varies  so  greatly  that  no  reliance  can 
be  placed  upon  the  result  of  this  part  of  the  examination,  from  the  fact 
that  some  were  weighed  in  the  dry,  and  others  in  the  fresh  state.  Sec- 
tions of  the  calculi  all  show  a  lamellar  arrangement,  beginning  at  the 
center,  which  indicates  the  manner  of  their  increase  in  size.  These 
calculi  form  very  slowly;  perhaps  years  elapse  before  their  presence 
gives  rise  to  any  serious  complications. 

Symptoms. — ^The  symptoms  are  acute  inflammation,  accompanied 
by  extensive  swelling  in  the  floor  of  the  mouth,  at  the  side  of  and 
beneath  the  tongue.  This  organ  is  sometimes  lifted  up  and  pushed 
back  into  the  fauces.  Fullness  of  the  submaxillary  triangle  of  the 
neck  is  also  observed.  The  pain  is  frequently  very  severe.  The  con- 
stitutional symptoms  are  elevation  of  temperature,  nausea,  dizziness, 
and  a  general  feeling  of  prostration.  Upon  an  examination  of  the 
swelling  by  palpation,  the  index  finger  of  one  hand  within  the  mouth, 

Fig.  147. 


Salivary  Calculus  from  the  Submaxillary  Gland  of  a  Horse.     (Reduced  one-half.) 

over  the  swelling,  and  the  other  upon  the  neck  beneath  the  gland,  the 
form  of  the  swollen  gland  and  duct  may  be  readily  outlined.  Occasion- 
ally the  calculus  can  be  found  as  a  hard  mass  within  the  duct.  This, 
however,  would  not  be  possible  when  the  swelling  was  at  all  extensive, 
or  the  calculus  was  located  within  the  gland.  Inflammation  and  sup- 
puration are  commonly  associated  at  various  intervals  with  the  pres- 
ence of  these  formations  in  the  gland  or  its  duct.  These  calculi  are 
usually  oblong  or  spindle-shaped  in  form.  In  size  they  have  varied 
from  one  grain  to  two  hundred  and  seventy,  the  latter  being  the  largest 
recorded  calculus  found  in  a  human  subject.  The  largest  calculus  in 
measurement  was  six  centimeters  in  length,  and  five  and  one-half  in 
width.  Usually  there  is  but  one  calculus  found  in  the  duct  or  the 
gland,  but  occasionally  two  or  more  are  found  lying  together,  facets 
having  formed  at  the  points  of  contact.  Garretson  mentions  a  case  in 
which  both  of  the  ducts  of  Wharton  were  filled  with  small  calculi. 
Salivary  calculi  are  quite  common  in  the  larger  animals,  like  the  horse 
and  the  ox.  The  accompanying  illustration  (Fig.  147)  is  a  calculus 
taken  from  the  submaxillary  gland  of  a  horse;  it  weighed  eleven  and 
one-half  ounces  in  the  dried  state,  and  measured  six  inches  in  length 
and  two  inches  in  width,  having  a  circumference  at  its  largest  part  of  six 


398  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

inches.  Although  inflammation  and  suppuration  are  commonly  recur- 
ring conditions,  an  external  fistula  as  a  result  is  an  exceedingly  rare  oc- 
currence. Fistula  following  operation  through  the  external  tissues  has 
occasionally  occurred,  and  it  is  somewhat  difficult  to  heal.  Relapses 
after  complete  removal  of  the  calculi  are  very  rare,  and  it  is  more  than 
likely  that  in  most  of  those  cases  reported  as  relapsing,  all  of  the  cal- 
culi were  not  removed  at  the  first  operation. 

Diagnosis. — The  diagnosis  is  usually  a  simple  matter.  If  the  duct 
is  still  patulous,  a  small  probe — preferably  made  of  untempered  steel, 
as  this  metal  conducts  sound,  and  the  vibrations  produced  by  contact 
are  much  better  than  the  ordinary  silver  probe — may  be  passed  into  it 
until  it  reaches  the  calculus,  which  will  be  distinguished  by  the  rough, 
grating  sensation  imparted  to  the  fingers  upon  bringing  the  probe  in 
contact  with  the  stone.  If  the  duct  is  not  open,  an  exploring  needle 
may  be  thrust  into  the  swelling  at  various  points,  when  if  a  calculus  is 

Fig.  148. 


Salivary  Calculus  from  the  Submaxillary  Gland.    (After  Fiitterer.) 

present  it  will  most  likely  be  found.  Cases  with  extensive  swelling  of 
a  chronic  character  have  been  mistaken  for  malignant  growths.  The 
difficulty  in  diagnosis  is  much  greater  when  the  calculus  is  situated  in 
the  gland  than  when  located  in  the  duct. 

Treatment. — The  usual  method  employed  for  removing  a  salivary 
calculus  from  either  of  the  glands  or  their  ducts  is  by  an  incision  made 
within  the  mouth  over  the  point  at  which  the  calculus  lies  imbedded, 
or  by  dilating  the  orifice  of  the  duct,  and  expressing  the  calculus  from 
its  bed;  or  by  lifting  it  out  with  the  forceps.  Occasionally  the  swelling 
will  be  so  great  that  none  of  these  methods  will  avail,  and  this  is  especi- 
ally true  of  those  cases  in  which  the  calculus  is  lodged  within  the  gland. 
Fiitterer  reports  a  case  of  this  character  which  was  seen  by  the  writer 
in  consultation,  in  which  two  calculi  (Fig.  148)  were  found  imbedded 
in  the  submaxillary  gland,  one  of  which  weighed  one  grain,  and  the 
other  twenty-three  grains.  In  this  case  there  was  extensive  suppura- 
tion and  great  swelling  which  had  lasted  for  several  days.  The  pres- 
ence of  the  calculi  was  demonstrated  by  passing  a  fine  probe  into  the 
duct  of  Wharton.  After  making  an  extensive  incision  down  to  the  cal- 
culi, and  repeated  unsuccessful  trials  to  grasp  and  remove  them,  the 


DISEASES   OF   THE    SALIVARY    GLANDS.  399 

effort  was  abandoned,  and  the  wound  packed  with  gauze.  On  the  next 
day  the  packmg  was  removed,  which  was  followed  by  a  profuse  dis- 
charge of  pus.  The  calculi  were  then  easily  grasped  and  removed  with 
a  pair  of  long  slender  forceps. 

Operations  through  the  external  tissues  for  the  removal  of  calculi 
are  to  be  deprecated,  on  account  of  the  dangers  of  forming  salivary 
fistulse.  The  after-treatment  in  these  cases  is  simple.  Thorough  clean- 
liness of  the  mouth  and  wound,  maintained  by  the  use  of  antiseptic 
solutions,  is  all  that  is  required. 

Salivary  Fistulas. — Salivary  fistula  is  a  rare,  but  nevertheless  a 
very  troublesome  affection.  It  is  usually  associated  with  the  duct  of 
the  parotid  gland,  and  is  very  rarely  met  with  in  the  submaxillary  or 
the  sublingual  glands. 

Causes. — It  may  be  caused  by  traumatic  or  surgical  injuries,  or  by 
inflammatory  conditions  resulting  in  abscess,  or  by  ulceration.  Lacer- 
ated and  gunshot  wounds  of  the  cheek,  and  surgical  operations  requir- 
ing incisions  of  the  cheek,  are  the  most  frequent  causes  of  the  affection. 
The  inflammatory  conditions  which  may  result  in  fistulse  of  the  parotid 
gland  are  suppurative  parotitis,  suppurative  inflammation  from  injury 
and  the  presence  of  calculi,  ulceration  following  mercurial  ptyalism, 
and  gangrenous  stomatitis.  Fistula  of  the  parotid  gland  has  some- 
times occurred  as  the  result  of  operations  upon  this  organ  for  the  re- 
moval of  tumors. 

Diagnosis. — The  affection  consists  of  an  outward  opening  of  the 
duct  of  Stenson  upon  the  external  surface  of  the  cheek,  through  which 
the  saliva  flows  over  the  cheek  instead  of  into  the  mouth.  During 
the  stimulation  of  the  gland  induced  by  the  act  of  mastication  or  the 
odors  of  appetizing  foods,  the  saliva  pours  out  over  the  cheek,  and  be- 
comes very  annoying.  Sometimes  the  cheek  is  excoriated  by  the  fluid, 
and  unhealthy  looking  granulations  spring  up  about  the  orifice  of  the 
fistula. 

Treatment. — A  variety  of  operations  have  been  proposed  for  the 
cure  of  this  affection.  They  all  have  the  same  end  in  view,  namely :  to 
re-establish  the  flow  of  saliva  into  the  mouth,  and  to  close  the  fistula 
upon  the  external  surface  of  the  cheek.  A  common  method  of  treat- 
ment is  by  cauterization  and  compression  of  the  fistula.  This  form  of 
treatment  may  occasionally  succeed  in  those  cases  in  which  the  natural 
orifice  in  the  mouth  still  remains  patulous.  In  the  greater  number  of 
cases,  however,  the  orifice  in  the  mouth  has  been  obliterated  and  calls 
for  an  operation  to  re-establish  it. 

Agnew's  method  consists  of  passing  a  curved  needle,  armed  with 
silk  thread,  around  the  duct,  posteriorly  to  the  fistula,  from  within  the 
mouth.  The  needle  should  be  entered  and  emerged  at  as  nearly  as 
possible  the  same  point,  care  being  taken  to  include  the  duct,  but  not 


400  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

the  skin,  within  the  loop.  The  thread  is  then  to  be  tightly  knotted,  and 
the  ends  cut  off.  The  effect  of  this  operation  is  to  produce  ulceration 
within  the  cheek,  while  the  ligature  cutting  its  way  through  the  con- 
fined tissue,  separates  after  a  few  days,  and  leaves  a  new  and  artificial 
duct  through  which  the  saliva  may  find  a  free  passage  into  the  mouth. 
If  the  external  fistula  does  not  close  immediately,  the  edges  may  be 
pared  and  brought  together  with  sutures,  and  covered  with  a  collodion 
dressing. 

Deguise's  method  consists  of  first  making  a  puncture  through  the 
fistulous  opening  in  the  cheek  obliquely  backward  to  the  inner  sur- 
face of  the  cheek,  and  passing  one  end  of  a  leaden  wire  through  it. 
Second,  through  the  same  opening  another  puncture  is  made,  which  is 
directed  obliquely  forward,  and  through  which  the  other  end  of  the 
wire  is  passed.  The  ends  of  the  wire  are  then  brought  together  and 
twisted.  The  loop  passing  through  the  fistula  conducts  the  saliva  into 
the  mouth,  and  the  fistula  closes  in  a  few  days.  If  it  does  not,  it  should 
be  closed  by  the  method  just  described. 

Van  Buren  succeeded  in  closing  a  salivary  fistula,  the  result  of  a 
gunshot  wound,  by  transferring  the  fistulous  orifice  from  the  outer  to 
the  inner  surface  of  the  cheek.  This  may  be  accomplished  by  first  pass- 
ing a  fine  silver  wire  through  the  skin  at  opposite  points  on  the  edge 
of  the  fistulous  orifice.  The  next  step  in  the  operation  is  to  loosen  the 
fistulous  orifice  and  the  duct  from  the  surrounding  tissue,  for  the  dis- 
tance of  about  half  an  inch  backward,  then  make  an  incision  through 
the  wound  to  the  inner  side  of  the  cheek,  drawing  the  fistulous  orifice 
through  it,  and  retaining  it  in  its  new  position  by  means  of  the  wire. 
The  external  opening  is  to  be  closed  with  silver  wire  sutures.  The 
wound  should  be  treated  antiseptically. 


CHAPTER    XLl. 

NEURALGIA. 

Definition. — Neuralgia  (Greek  vevpov,  nerve;  uAyo?,  pain). 

Neuralgia  is  a  severe  paroxysmal  pain  in  the  area  of  distribution 
of  a  nerve,  or  along  its  course. 

It  has  become  customary  to  designate  all  pains  which  occur  in 
paroxysms,  unattended  with  local  or  general  elevation  of  temperature, 
and  distributed  along  the  course  of  nerve-trunks  or  nerve-branches, 
for  which  no  adequate  cause  can  be  assigned,  as  neuralgia.     (Putnam.) 

Neuralgia  is  not  a  disease,  nor  a  morbid  condition  in  the  sense  of 
its  having  an  individuality,  but  is  a  phenomenon,  or  an  expression  of 
a  disease  or  of  a  morbid  general  or  local  condition.  Neuralgia  has 
been  called  "the  prayer  of  the  nerves  for  blood,"  and  "the  cry  of  the 
hungry  nerves  for  food,"  but  these  suggestions  as  to  the  etiology  of 
neuralgia  do  not  cover  all  the  causes  which  produce  this  most  distress- 
ing and  painful  phenomenon. 

Neuralgia  is  a  medical  rather  than  a  surgical  affection,  and  rarely 
comes  under  the  observation  of  the  surgeon  except  as  the  result  of 
injurv,  or  the  implication  of  the  nerves  in  the  healing  of  wounds  or 
cicatrices,  or  when  medical  treatment  has  failed  to  relieve  the  pain  and 
surgical  operation  is  sought  as  a  last  resource. 

The  conditions  which  are  productive  of  neuralgia  are  many  and 
varied,  and  consist  chiefly  of  diseases  which  lower  the  vital  powers  of 
the  system,  such  as  anemia,  or  those  which  interfere  with  such  func- 
tions as  the  circulation,  respiration,  digestion,  assimilation,  secretion, 
and  elimination;  the  presence  in  the  system  of  abnormal  substances, 
as  in  gout,  rheumatism,  diabetes,  malaria,  nephritis,  chronic  pyemia» 
syphilis,  and  metallic  poisoning;  local  conditions  which  cause  reflex 
peripheral  irritation,  such  as  diseases  of  the  teeth,  eyes,  ears,  stomach, 
uterus,  and  ovaries;  chronic  inflammation  of  the  nerve  or  its  sheath; 
pressure  from  abnormal  growths  within  the  bony  canal  through  which 
the  nerve-trunk  passes,  or  pressure  from  tumors,  and  localized  anemia 
or  congestion  of  nerves  or  nerve-centers. 

Neuralgia  may  therefore  be  the  result  of  an  actual  diseased  condi- 
tion of  the  nerve,  as  for  instance  in  a  neuritis,  or  it  may  exist  with  no 
discernible  structural  change  in  the  nerve-tissue  or  the  nerve-centers. 

27  401 


402  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

The  changes  which  may  take  place  in  the  nerve-tissue  under  such 
conditions  may  be  simply  molecular,  and  these,  with  our  present  means 
of  examination,  are  not  capable  of  being  demonstrated;  but  the  way  in 
which  certain  forms  of  neuralgia  behave,  as  for  instance  their  sudden 
disappearance  from  one  part  to  reappear  in  another  and  perhaps  re- 
mote location,  or  their  complete  disappearance  after  a  short  period, 
confirms  the  general  opinion  that  these  forms  are  not  due  to  any  or- 
ganic change  in  the  nerve  itself. 

On  this  account  it  has  become  customary  to  divide  all  neuralgias 
into  two  distinct  classes,  placing  those  in  which  there  are  appreciable 
changes  in  the  nerve-tissue  under  the  head  of  symptomatic  neuralgia, 
and  all  others  under  the  head  of  idiopathic  neuralgia. 

In  symptomatic  neuralgia  the  pain  is  dependent  upon  the  neu- 
ritis or  other  structural  changes  in  the  nerve-tissue  or  its  sheath,  while 
in  idiopathic  neuralgia  the  pain  does  not  depend  upon  any  discoverable 
change  or  alteration  in  the  nerve-tissue.  Of  the  pathologic  anatomy 
of  such  a  condition  there  is  absolutely  nothing  known. 

In  the  character  of  the  pain  in  these  two  varieties  of  neuralgia, 
there  is  very  little  difference ;  but  the  symptoms  which  accompany  the 
pain  are  not  alike.  The  principal  difference  in  the  symptoms  lies  in  the 
greater  degree  of  pain  manifested  in  a  neuritis,  and  the  sensitiveness 
which  exists  over  the  nerve-trunk.     (Sinkler.) 

All  neuralgias  have  one  common  tendency,  which  is  manifested  in 
a  greater  or  less  degree,  viz:  periodic  recurrences,  but  the  degree  of 
periodicity  varies  greatly.  These  recurrences  are  most  regular  and 
best  marked  in  the  malarial  neuralgias,  and  in  those  dependent  upon 
neurotic  conditions  like  migraine  and  the  periodic  headaches. 

Neuralgia  affecting  the  viscera  occurs  with  less  regularity.  One 
variety  of  neuralgia  affecting  the  ophthalmic  division  of  the  trifacial 
nerve  evinces  a  tendency  to  daily  recurrences  at  the  same  hour  (usually 
about  nine  a.m.)  for  a  certain  period.  This  is  particularly  marked  in 
those  cases  dependent  upon  malarial  influences,  and  catarrhal  affec- 
tions of  the  frontal  sinuses.  The  writer  had  under  observation  recently 
a  case  of  this  character  which  was  due  to  catarrhal  inflammation  of  the 
frontal  sinuses.  The  pain  was  intense  for  an  hour  to  an  hour  and  a  half, 
the  paroxysms  being  from  three  to  five  minutes  apart.  The  patient 
complained  of  a  stopped-up  feeling  in  the  nasal  passages  and  a  sense  of 
fullness  in  the  frontal  region  on  rising  in  the  morning.  This  lasted  until 
the  paroxysms  ceased,  when  the  sense  of  fullness  also  disappeared. 
The  patient  made  constant  effort  during  the  period  of  the  paroxysm  to 
clear  the  nasal  passages,  and  he  believed  that  as  soon  as  this  effort  was 
successful  the  pain  ceased. 

The  neuralgias  are  also  again  divided  according  to  their  location 
and  their  symptomatology,  into, — 


NEURALGIA.  403 

1.  Superficial. 

2.  Visceral. 

3.  Migraine  and  the  migrainoid  headaches. 

The  siipcrhcial  variety  of  neuralgia  is  limited  to  the  course  and 
area  of  distribution  of  a  single  superficial  nerve  or  group  of  nerves, 
like  tlie  sciatic  and  the  trifacial. 

The  z'isccral  forms  of  neuralgia  are  less  definitely  localized  by  the 
sensations  of  the  patient  than  in  the  superficial  variety,  and  as  these 
nerves  are  deep-seated  it  is  dififiicult  to  indicate  which  are  at  fault. 

Migraine  is  a  complex  sensory  neurosis  characterized  by  pain  in 
various  locations  of  the  cranium;  the  occipital  region,  the  vertex,  the 
frontal,  or  the  temporal  region. 

Causes. — The  causes  of  neuralgia  may  be  divided  into  two  forms, 
predisposing  and  exciting. 

The  predisposing  causes  are, — 

1.  Hereditary  tendencies. 

2.  Periods  of  life  at  which  certain  critical  changes  take  place. 

3.  Influences  associated  with  sex. 

4.  The  effects  of  constitutional  diseases,  such  as  anemia,  gout, 
rheumatism,  phthisis,  diabetes,  nephritis,  malaria,  syphilis,  and  metallic 
poisoning. 

The  exciting  causes  are, — 

1.  Atmospheric  conditions,  as  indicated  by  a  low  barometer;  and 
the  local  action  of  heat  and  cold. 

2.  Injuries  and  direct  irritation  of  the  nerves. 

3.  Indirect  irritation  of  the  nerves  (reflex). 

4.  Acute  febrile  diseases. 

Predisposing^  Causes. — Hereditary  Tendencies:  The  fact  of  the  in- 
heritance of  neuralgic  tendencies  by  certain  families  who  give  other 
signs  of  a  neuropathic  taint,  is  so  well  established  that  it  does  not  admit 
of  question.  The  tendency  is  most  marked  in  the  case  of  migraine, 
and  other  periodic  headaches.  It  is  also  noticed  in  visceral  neuralgias, 
and  particularly  so  in  facial  neuralgias,  though  less  marked  in  the  other 
forms  of  superficial  neuralgias.     (Putnam.) 

Age:  Age  is  an  important  factor  in  the  predisposition  to  neural- 
gic affections,  which  are  most  common  in  middle  life,  and  at  those 
periods  which  mark  the  growth  and  the  decline  of  the  sexual  functions. 
According  to  Anstie,  these  conditions  when  once  established  are  in- 
clined to  continue  into  advanced  age,  but  fortunately  cases  beginning 
at  this  period  are  relatively  rare,  though  exceedingly  intractable. 

Childhood  and  youth  are  usually  exempt  from  superficial  neural- 
gias, though  migraine  and  periodic  headaches  may  develop  in  children 
of  neurotic  temperament.  These  conditions  may  later  in  life  give  way 
to  more  serious  neuroses. 


404  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

Sex:  Women,  as  a  rule,  are  more  liable  to  certain  forms  of  neu- 
ralgia than  are  men.  This  is  particularly  noticeable  in  neuralgias  of 
the  trifacial,  occipital,  and  intercostal  nerves;  while  men  suffer  most 
frequently  from  the  brachial,  crural,  and  sciatic  neuralgias.  Putnam 
thinks  this  is  due  to  the  stronger  neurosal  element  in  women,  and  the 
neuritic  element  in  men. 

Constitutional  Diseases:  Any  and  all  constitutional  disorders  which 
by  virtue  of  their  action  produce  an  impoverished  condition  of  the 
blood  or  retrograde  tissue-changes,  or  the  disturbance  of  vital  or  other 
important  functions  of  the  body,  undoubtedly  predispose  to  neuralgia 
and  other  neurotic  affections.  Among  these  predisposing  constitu- 
tional causes  may  be  mentioned  phthisis,  anemia,  gout,  rheumatism, 
diabetes,  malaria,  nephritis,  chronic  pyemia,  syphilis,  indigestion,  mal- 
assimilation,  perversions  in  secretion  and  elimination,  conditions  of  the 
vaso-motor  system  which  produce  local  congestion  or  anemia,  and  the 
presence  within  the  system  of  certain  toxic  substances  such  as  the 
metallic  poisons.  Ehrmann  has  published  an  account  of  four  cases  in 
which  small  doses  of  potassium  iodid  produced  trigeminal  neuralgia. 

Lead,  arsenic,  antimony,  and  mercury  are  all  capable  under  favor- 
ing circumstances  of  so  impairing  the  nutrition  of  all  nerve-tissue  as  to 
seriously  predispose  it  to  neuralgic  attacks. 

Exciting  Causes. — Atmospheric  conditions,  and  Thermal  influences: 
It  has  long  been  known  that  certain  atmospheric  conditions,  especially 
those  preceding  a  storm,  were  likely  to  excite  attacks  of  neuralgia,  and 
that  the  various  forms  of  neuralgia  were  more  prevalent  in  the  cold 
and  damp  seasons  of  the  year,  in  cold  and  damp  localities,  and  in  per- 
sons whose  occupations  compelled  them  to  work  in  a  cold  and  moist 
atmosphere,  or  who  were  subject  to  frequent  and  extreme  changes  of 
temperature,  than  under  different  circumstances. 

In  a  series  of  observations  conducted  by  a  miHtary  officer  under 
the  direction  of  S.  Weir  Mitchell,  in  relation  to  the  conditions  of  the 
atmosphere  preceding  a  storm  and  the  coincident  attacks  of  neuralgia 
in  the  stump  of  an  amputated  limb,  from  which  the  officer  suffered 
most  intensely,  it  was  found  that  the  attacks  of  pain  were  accompanied 
by  a  falling  barometer,  though  the  severity  of  the  pain  did  not  neces- 
sarily bear  a  proportionate  increase  with  the  rapidity  or  the  extent  of 
the  fall.  The  moisture  of  the  atmosphere  seemed  to  have  a  certain 
effect,  but  the  attacks  occurred  even  when  the  storm  center  was  so  far 
removed  that  no  local  rainfall  took  place.  The  electrical  disturbances 
of  the  atmosphere  could  not  be  studied  with  accuracy,  but  there  seemed 
to  be  a  certain  relationship  between  the  attacks  of  pain  and  the  appear- 
ance of  the  aurora  borealis.     (Putnam.) 

Injuries  and  Direct  Irritation  of  the  Nerves. — Among  the  principal 
exciting  causes  of  this  class  may  be  named  wounds  and  injuries  to 


NEURALGIA. 


405 


the  nerves;  impingement  of  nerves  within  cicatricial  tissue;  pressure 
from  neoplasms  and  certain  inflammatory  swellings  (gumma,  etc.); 
narrowing-  of  the  bony  canals  and  foramina,  and  aneurisms. 

The  writer  reported  a  case  at  the  Ninth  International  Medical 
Congress,  of  persistent  neuralgia  of  the  temporo-maxillary  articulation 
of  eight  years'  standing,  which  was  due  to  the  malposition  of  the  right 
ramus,  caused  by  exsection  of  a  portion  of  the  jaw, — from  the  angle  to 
the  first  bicuspid  tooth, — and  contraction  of  the  cicatricial  tissue,  which 
was  entirely  cured  by  an  operation  which  replaced  the  ramus  in  its  nor- 
mal position  and  thereby  relieved  the  tension  upon  the  articular  liga- 
ments of  the  joint.     The  case  has  already  been  referred  to  in  another 

Fig.  1 40. 


Malposition  of  the   Right   Ramus,   the   Result  of  Partial  Exsection  of  the  Jaw  for 
Sarcoma,  which  caused  Persistent  Temporo-Maxillary  Neuralgia. 


chapter  as  an  example  of  bone-grafting.  Fig.  149  is  an  illustration  of 
the  position  of  the  ramus  before  the  operation,  and  Fig.  150  shows  it 
one  year  after  the  operation,  the  teeth  having  been  lost  by  pyorrhea 
alveolaris. 

Indirect  Irritation  of  the  Nerves. — Under  this  class  of  exciting 
causes  are  grouped  all  those  disorders  which  produce  these  effects 
through  reflex  or  sympathetic  action.  As  an  illustration,  diseases  of 
the  uterus  and  ovaries  not  infrequently  cause  reflex  facial,  mammary, 
intercostal,  and  gastric  neuralgia.  The  writer  for  several  years  had 
under  observation  a  suft'erer  from  dyspepsia  accompanied  by  severe 
gastralgia  and  reflected  neuralgic  paroxysms  in  the,  left  brachial 
plexus.  The  reflected  pain  was  always  in  the  same  location,  and  often 
of  so  severe  a  type  as  to  greatly  interfere  with  the  use  of  the  arm  upon 
the  following  day  on  account  of  the  soreness  of  the  muscles. 


4o6 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


The  eye  is  an  important  center  of  nervous  irritation,  and  errors 
of  refraction,  even  when  quite  slight,  are  sometimes  productive  of 
migraine.  Inflammatory  conditions  of  an  acute  and  chronic  nature 
affecting  the  maxillary  and  frontal  sinuses  are  also  productive  of 
neuralgic  attacks. 

Acute  Febrile  Diseases. — Acute  fevers  are  occasionally  the  exciting 
cause  of  neuralgia.  Thus,  Nothnagel  describes  neuralgias  which  came 
on  during  the  first  week  of  typhoid  fevers.  Putnam  mentions  a  case 
which  came  under  his  own  observation,  in  which  "a  severe  facial  neu- 
ralgia appeared  during  the  first  Aveek  of  an  insidious  attack  of  pneu- 
monia in  an  individual  who  was  not  of  neuralgic  habit,  and  before  the 
fever  or  inflammation  had  become  at  all  severe." 


Fig.  150. 


Final  Result,  One  Year  after  Operation.    Teeth  were  Lost  by  reason  of   Pyorrhea 

Alveolaris. 

It  is  possible  that  other  acute  affections  may  have  a  similar  effect. 

Trifacial  Neuralgia. — From  the  surgical  standpoint  the  super- 
ficial forms  of  neuralgia  are  the  only  varieties  of  especial  niterest  to  the 
surgeon,  as  these  only  are  amenable  to  treatment  by  surgical  proced- 
ures. 

Neuralgia  of  the  trifacial  and  sciatic  nerves,  the  brachial  plexus, 
and  the  neuralgia  of  stumps  and  scars,  are  the  most  common  forms  of 
the  superficial  affection. 

Neuralgia  of  the  trifacial  nerve  (tic  douloureux)  is  the  form  which 
most  frequently  comes  under  the  observation  of  the  dentist  and  the 
oral  surgeon. 

Trifacial  or  trigeminal  neuralgia  appears  in  two  forms,  viz:  acute 
and  chronic. 

The  acute  form  of  the  affection  is  frequently  associated  with  or  de- 
pendent upon  acute  inflammatory  conditions  of  the  teeth  and  alveolar 


NEURALGIA.  407 

processes,  acute  affections  of  the  eye  and  ear,  and  of  the  maxillary  and 
frontal  sinuses.  Thfs  form  of  neuralgia  is  usually  of  short  duration, 
and  gfenerally  disappears  upon  the  subsidence  or  the  removal  of  the 
exciting-  cause. 

The  chronic  form  is  often  persistent  in  its  character;  the  exciting 
cause  difficult  to  find;  and  the  affection  does  not  always  disappear  upon 
the  removal  of  the  supposed  cause  on  account  of  the  structural  changes 
which  may  have  taken  place  in  the  nerve-tissue  or  the  sheath  of  the 
affected  branches  or  of  their  blood-vessels.  It  not  infrequently  hap- 
pens that  more  than  one  abnormal  local  or  constitutional  factor  may 
be  involved  in  the  causation  of  the  various  forms  of  neuralgia;  failure 
in  one  direction  should  therefore  lead  to  renewed  search  in  some  other, 
with  the  hope  of  finally  discovering  the  other  factors  in  the  case,  and 
removing  them  if  possible. 

Xeuralgia  may  exist  in  any  of  the  nerves  of  the  body  as  a  result 
of  neuritis,  but  it  is  most  frequently  observed  in  the  sciatic  and  trifacial 
nerves. 

The  frequency  with  which  the  various  branches  of  the  trifacial 
nerve  are  the  seat  of  neuralgia  may  be  stated  to  occur  in  the  following 
order:  the  superior  maxillary  division,  the  inferior  maxillary  division, 
and  lastly,  the  ophthalmic  division. 

In  neuralgia  of  the  superior  maxillary  division,  the  pain  is  some- 
times located  in  the  dental  branches,  being  referred  to  the  upper  teeth, 
gums,  and  maxillary  bone;  at  other  times  it  affects  the  infraorbital 
branch,  the  pain  being  referred  to  the  integument  of  the  cheek,  the  side 
of  the  nose,  and  the  upper  lip. 

Infraorbital  neuralgia  is  frequently  associated  with  neuralgia  of 
one  of  the  other  branches  of  the  fifth  nerve,  usually  with  the  first 
division. 

When  affecting  the  inferior  division,  the  pain  is  most  frequently 
located  in  the  lower  teeth,  the  gums,  and  the  integument  of  the  lower 
lip  and  the  chin. 

\\'hen  located  in  the  ophthalmic  division  it  most  often  affects  the 
supraorbital  branch,  the  pain  spreading  out  over  the  forehead,  the 
eyebrow,  and  the  upper  eyelid.  It  is  a  common  occurrence  for  the 
patient  to  refer  the  pain  in  the  beginning  of  a  paroxysm  to  the  point  of 
exit  of  the  nerve  from  its  bony  canal,  for  instance  at  the  infraorbital, 
mental,  and  supraorbital  foramina. 

Sympionis. — Neuralgia  of  the  fifth  nerve  rarely  appears  until  after 
middle  life,  and  in  old  persons  it  frequently  resists  the  most  intelligent 
treatment.  The  fact  that  the  affection  does  not  appear  as  a  rule  until 
after  middle  life,  when  the  senile  changes  are  beginning  to  take  place, 
would  seem  to  indicate  a  connection  between  these  changes  and  the 
appearance  of  this  form  of  neuralgia. 


408  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

The  pain  is  of  the  most  excruciating  character.  There  is  no  other 
disease,  with  possibly  the  exception  of  tetanus,  which  from  the  severity 
of  the  suffering  is  so  calculated  to  arouse  the  sympathies  and  com- 
miseration of  the  surgeon  and  those  in  attendance  upon  the  case,  as 
the  severe  forms  of  tic  douloureux. 

In  tic  douloureux,  or  "epileptiform  neuralgia,"  as  Trousseau 
termed  it,  the  pain  comes  on  suddenly,  sometimes  preceded  as  in  epi- 
lepsy by  an  aura.  The  character  of  the  pain  is  acute,  occurring  in  dis- 
tinct paroxysms,  with  longer  or  shorter  intervals,  sharp,  stinging,  or 
lancinating,  gradually  increasing  in  intensity  for  a  few  moments,  until 
it  reaches  a  climax,  and  as  gradually  and  quickly  subsiding,  to  be  again 
followed  by  another  paroxysm  of  equal  degree  of  intensity.  The  pain 
is  so  fearfully  severe  in  some  cases  as  to  cause  the  patient  to  moan  or 
cry  aloud  with  every  paroxysm,  and  after  the  paroxysm  is  past  to  sit  in 
terror  waiting  the  onset  of  the  next  attack.  This  may  continue  for 
hours  without  cessation,  or  the  paroxysms  may  last  but  for  an  hour  or 
two,  the  remainder  of  the  day  being  quite  free  from  pain;  or  it  may  be 
excited  at  any  time  by  talking,  laughing,  mastication,  or  even  passive 
movements  of  the  muscles  of  mastication,  speech,  or  expression.  A 
slight  noise  or  a  light  touch  may  precipitate  a  paroxysm. 

In  some  cases  the  patient  will  be  entirely  free  from  pain  during 
the  night,  but  upon  awakening  in  the  morning  the  slightest  movement 
of  the  muscles  of  the  face  precipitates  the  paroxysms  of  pain.  Occa- 
sionally the  pain  will  be  severe  during  the  night,  and  the  patient  com- 
paratively free  during  the  day,  and  able  to  go  about  his  daily  vocation ; 
while  in  others  the  pain  may  be  induced  at  any  time  by  the  movement 
of  the  muscles,  so  that  the  question  of  taking  food  becomes  for  several 
days  at  a  time  one  of  great  dread;  in  fact,  patients  frequently  abstain 
from  the  taking  of  aliment  except  in  a  liquid  form  for  days  together. 
The  pain  and  the  dread  of  the  returning  paroxysms  make  life  a  burden. 

Besides  the  pain,  other  symptoms  of  lesser  note  occur  in  facial 
neuralgia.  Increased  secretion  of  the  lachrymal,  salivary,  and  mucous 
glands  is  a  frequent  occurrence.  The  hair  of  the  face  or  side  of  the  head 
becomes  dry  and  brittle,  and  is  inclined  to  fall  out,  or  it  may  lose  its 
color  rapidly,  regaining  it  after  the  attack  has  passed.  (Putnam.) 
There  is  increased  secretion  of  urine.  Anstie  noticed  unilateral  furring 
of  the  tongue.  The  muscles  to  which  the  pain  is  referred  may  some- 
times become  paretic.  Temporary  amaurosis,  and  sometimes  loss  of 
the  eye  of  the  affected  side,  may  take  place  in  tic  douloureux.  The 
senses  of  hearing,  taste,  and  smell  may  likewise  be  temporarily  lost. 

Causes. — Among  the  more  common  exciting  causes  of  trifacial 
neuralgia  expressed  in  the  various  divisions  of  the  fifth  nerve,  may  be 
mentioned  the  following  conditions:  In  the  ophthalmic  division  in- 
flammatory affections  of  the  conjunctivae,  diseases  of  the  globe  of  the 


NEURALGIA.  409 

eye  and  iritis,  and  catarrhal  conditions  of  the  frontal  sinuses.  In  the 
superior  and  inferior  maxillary  divisions,  inflammatory  conditions  of 
the  teeth  and  jaws,  particularly  pulpitis,  pericementitis,  and  periostitis 
of  the  alveolar  processes;  structural  changes  in  the  teeth,  like  inter- 
stitial calcification  of  the  pulp,  pulp-nodules,  and  exostosis  of  the  root. 
Fig.  151  is  from  a  case  of  neuralgia  of  the  third  division  of  the  trifacial 
nerve  induced  by  the  formation  of  a  pulp-nodule.  Difficult  erup- 
tion of  the  teeth,  particularly  of  the  lower  third  molars;  exposed  sensi- 
tive dentine  from  caries,  abrasions,  or  fractures  which  have  caused  a 
loss  of  the  enamel ;  and  lastly,  inflammatory  and  other  diseased  condi- 
tions of  the  maxillary  sinuses,  which  are  particularly  associated  with 
neuralgia  of  the  superior  maxillary  division. 

Syphilitic  manifestations  of  a  secondary  and  tertiary  nature  may 
produce  inflammatory  infiltration  of  the  nerve-sheath,  or  neuritis,  and 
cause  neuralgia  in  either  or  all  of  the  branches  of  the  fifth  nerve. 
Osseous  growths  within  the  bony  canals  or  the  foramina  through 
which  these  nerves  pass  is  not  an  infrequent  exciting  cause  of  neural- 
gia. These  growths  may  be  in  the  form  of  tubercles  arising  from  the 
walls  of  the  canals,  or  in  the  form  of  a  diffuse  exostosis ;  in  either  case  a 
narrowing  of  the  canal  or  its  foramen  is  the  result,  pressure  upon  the 
nerve  is  induced,  and  as  the  patient  grows  older  there  is  caused  a  pro- 
gressive neuralgia. 

The  various  forms  of  irritation,  both  direct  and  indirect,  not  infre- 
quently set  up  a  neuritis  in  the  various  branches  of  the  nerve,  as  dem- 
onstrated by  Putnam  and  others.  Dana  found  striking  evidences  of 
arterial  disease  in  three  cases  of  typical  trifacial  neuralgia,  but  no  note- 
worthy changes  in  the  nerves.  He  believes  the  cause  of  neuralgia  to 
"be  obliterating  arteritis,  and  gives  as  his  reasons  for  this  opinion  that 
"the  disease  occurs  at  an  age  when  degenerative  changes  begin  in  the 
arteries  and  follow  a  certain  fixed  distribution." 

Tuffler  found  positive  evidence  of  neuritis  in  one  case  examined 
by  him  of  neuralgia  of  the  inferior  maxillary  nerve.  In  this  case  the 
nerve  was  "swollen  and  reddened  both  within  the  dental  canal  and 
before  its  entrance."  Sinkler  also  found  like  evidences  of  neuritis  in  a 
•case  of  neuralgia  of  the  inferior  maxillary  nerve. 

Diagnosis. — The  manifestations  of  trifacial  neuralgia  are  so  char- 
acteristic that  an  error  in  the  diagnosis  could  hardly  be  made.  Valleix 
discovered  certain  points  of  tenderness  in  cases  of  facial  neuralgia 
which  are  designated  as  "points  douleureux."  These  are  located  in  the 
ophthalmic  division,  at  the  supraorbital  foramen,  on  the  upper  eyelid, 
at  the  line  of  union  of  the  nasal  bone  with  the  cartilage,  at  the  inner 
angle  of  the  orbit,  and  in  the  eyeball  itself.  Another  point  is  near  the 
parietal  eminence. 

In  the  superior  maxillary  branch  the  painful  points  are  situated 


4IO 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


at  the  infraorbital  foramen ;  at  a  point  over  the  most  prominent  part  of 
the  malar  bone;  an  uncertain  point  on  the  gum  of  the  superior  maxilla^ 
a  similar  point  upon  the  upper  lip,  and  another  upon  the  palate. 


Fig.  151. 


Inferior  Moi.ar — \'ertical  Section. 
Showing  Pulp-nodule  ("eiilargedi. 


NEURALGIA.  4II 

In  the  inferior  maxillary  division  the  painful  points  are  found  over 
the  auriculo-temporal  branch  just  in  front  of  the  ear;  another  over  the 
inferior  dental  foramen,  and  still  another  over  the  mental  foramen. 
The  presence  or  absence  of  these  "points  douloureux"  are  not  positive 
diag'nostic  signs,  though  as  a  general  rule  tenderness  will  be  found 
over  the  foramina  named. 


CHAPTER  XLII. 
TREATMENT  OF  TRIFACIAL  NEURALGIA. 

Trifacial  neuralgia  is  sometimes  amenable  to  treatment  by  cer- 
tain drugs.  Their  therapeutic  effect  is,  however,  often  very  disappoint- 
ing, and  one  after  another  may  be  tried  with  little  or  perhaps  no  benefit. 
Success  in  the  direction  of  treatment  by  drugs  will  depend  upon  the 
age  and  the  general  condition  of  the  patient,  and  the  causative  agents 
which  are  responsible  for  the  affection.  It  must  be  regarded,  how- 
ever, as  one  of  the  most  intractable  of  diseases.  The  long  list  of 
remedies  which  have  been  recommended  from  time  to  time  attest  the 
difficulties  that  are  met  with  in  attempts  to  eradicate  the  disease. 

It  is  especially  necessary  in  the  treatment  of  facial  neuralgia  to 
look  beyond  the  relief  of  the  particular  attack  under  observation  and 
search  for  the  cause  or  causes  which  have  provoked  the  attack. 
These  conditions  have  already  been  referred  to,  and  should  receive  that 
treatment  which  is  appropriate  to  the  individual  ailment. 

It  may  be  assumed,  however,  that  in  a  majority  of  the  cases  of 
protracted  neuralgia,  neuritis  is  present,  and  this  condition  should  re- 
ceive appropriate  treatment  by  local  applications  and  galvanism. 

As  many  cases  of  trifacial  neuralgia  are  due  to  the  impairment  of 
the  general  health,  remedies  which  are  directed  to  the  building-up  of 
the  system  are  sometimes  successful  in  curing  the  affection. 

Quinin,  arsenic,  a.nd  iron  have  been  found  useful  in  this  direction; 
the  precipitated  subcarbonate  of  iron  administered  in  large  doses  has 
been  found  exceedingly  beneficial.  Gclsemiiim  has  been  found  by 
many  authorities  to  be  one  of  the  most  potent  remedies  in  the  treat- 
ment of  neuralgias  of  the  fifth  nerve.  It  gives  its  best  results,  how- 
ever, in  those  cases  which  are  dependent  upon  diseased  conditions  of 
the  teeth.  Sinkler  has  found  it  useful  in  neuralgia  of  all  the  branches 
of  the  fifth  nerve.  The  writer  has  had  a  like  experience  in  most  of  the 
cases  in  which  it  has  had  a  fair  trial.  In  one  case,  however,  recently 
under  his  care,  this  drug  at  first  gave  complete  relief  administered  in 
the  form  of  sulfate  gclseminine,  gr.  1-30  every  two  hours  until  the  con- 
stitutional effect  was  produced.  In  the  next  attack,  which  came  on 
seven  days  afterward,  it  had  no  appreciable  effect  when  carried  to  the 
point  of  drooping  eyelids  and  dimness  of  vision.  The  fluid  extract  is 
412 


TREATMENT    OF    TRIFACIAL    NEURALGIA.  413 

generally  considered  the  best  preparation,  but  because  of  its  unrelia- 
bility in  strength  the  writer  prefers  the  sulfate  gelseminine . 

Valerianate  of  zinc  was  at  one  time  highly  recommended,  but  it 
is  not  at  the  present  time  held  in  much  esteem. 

Cannabis  indica  is  a  remedy  of  value  in  some  cases.  To  obtain 
the  best  results  it  should  be  given  in  full  doses,  and  repeated  as  often 
as  the  patient  can  tolerate. 

Seguin  and  others  have  highly  recommended  the  use  of  aconite. 
This  drug,  to  be  of  value,  should  be  administered  until  numbness  and 
tingling  are  felt  in  the  lips  and  face.  It  should,  however,  be  adminis- 
tered with  great  caution.  Its  value  no  doubt  lies  in  its  power  to  dimin- 
ish arterial  tension. 

Belladonna^  though  highly  recommended,  does  not  appear  to  re- 
ceive the  confidence  of  the  profession  as  a  valuable  remedy. 

Thompson  has  recommended  phosphorus  in  large  doses  for  its 
curative  effects.  Gow^ers  reports  a  case  that  was  entirely  relieved  by 
a  three  months'  treatment  with  phosphorus.  Others,  however,  have 
not  succeeded  in  obtaining  the  same  results.  It  has  the  objection  of 
being  irritating  to  the  stomach. 

Cimicifiiga  combined  with  cannabis  indica  has  been  extolled  as 
valuable  in  those  cases  dependent  upon  or  connected  with  rheumatism. 

Ringer,  Hare,  and  others  have  highly  recommended  croton 
chloral — butyl  chloral — in  the  treatment  of  tic  douloureux.  Hare 
administers  it  in  five-grain  doses  every  two  hours,  and  finds  that  its 
influence  is  not  only  palliative  but  curative.  Antipyrin,  phenacetin, 
and  salol  have  all  been  recommended  as  valuable  agents,  particularly 
in  the  rheumatic  forms  of  the  affection. 

Opium  has  no  curative  value,  but  it  is  often  necessary  to  adminis- 
ter morphin  hypodermically  to  control  the  severe  paroxysms  of  pain. 

Cocain  is  sometimes  administered  in  the  same  manner,  and  for  the 
same  purpose. 

In  cases  presenting  a  syphilitic  history,  iodid  of  potassium  in 
twenty-grain  doses,  increased  to  thirty  or  forty  grains  three  times  per 
day,  has  sometimes  proved  curative. 

Electricity,  when  judiciously  applied,  is  of  great  value.  The  gal- 
vanic current  is  the  most  beneficial.  Authorities  differ  as  to  which 
pole  should  be  applied  to  the  painful  spot.  Sinkler  recommends  the 
negative  pole.  Gowers  thinks  the  direction  of  the  current  is  of  no  great 
importance.  The  writer  uses  the  positive  pole  at  the  painful  spot,  and 
a  current  of  from  one  to  three  milliamperes.  The  current  may  be 
applied  for  from  two  to  five  minutes. 

As  local  applications,  menthol  and  the  oil  of  peppermint  often  afford 
temporary  relief. 

Surgical    Treatment. — Various    surgical    operations    have    been 


414  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

recommended  for  the  relief  of  superficial  neuralgia.  These  opera- 
tions are,  subcutaneous  division  of  the  trunk  of  the  nerve,  resection  of 
the  trunk  of  the  nerve,  nerve-stretching,  evulsion,  and  the  tying  of 
arteries  leading  to  nerve-trunks  and  nerve-centers. 

Subcutaneous  division  of  nerves  is  productive  of  immediate  relief 
from  the  pain  for  a  short  time,  but  eventually,  after  a  few  weeks  or 
months,  the  pain  returns  as  a  result  of  the  reunion  of  the  divided  nerve. 

The  division  of  a  nerve  as  shown  by  Waller  in  experiments  upon 
warm-blooded  animals,  produces  in  order  of  time : 

First.  Paralysis  of  motion,  or  of  sensation,  or  of  both  according 
as  the  nerve  which  has  been  divided  is  motor,  sensory,  or  mixed ;  this 
paralysis  is  immediate  and  local. 

Second.  Loss  of  excitability  of  the  nerve,  coming  on  gradually 
and  becoming  complete  within  a  few  days;  direct  muscular  excitabil- 
ity persisting  for  an  indefinite  time,  especially  to  the  galvanic  current. 

Third.  Degeneration  of  the  peripheral  end  of  the  nerve,  also  a 
gradual  process,  visible  within  a  day  or  two,  well  marked  at  the  end 
of  three  or  four  days,  and  complete  in  about  ten  days. 

Fourth.  Regeneration  of  the  previously  fully  degenerated  periph- 
eral end  of  the  nerve,  a  still  more  gradual  process,  commencing  in- 
definitely, but  clearly  visible  about  a  month  after  the  lesion  has  been 
produced  and  requiring  from  three  to  six  months  to  complete  itself; 
which  results  in : 

Fifth.     Restored  sensibility,  motility,  and  excitability. 

Excision  gives  somewhat  better  results,  in  that  the  interval  be- 
tween the  operation  and  the  return  of  the  pain  is  much  longer;  usually 
there  is  complete  relief  for  six  or  seven  months  and  occasionally  for 
two  or  three  years.  As  a  rule,  the  more  extensive  the  piece  removed, 
the  longer  will  relief  be  afforded.  It  is  customary  to  remove  at  least 
half  an  inch,  and  as  an  added  safeguard  against  reunion,  to  bend  back 
the  peripheral  end  of  the  segment  upon  itself. 

Nerve-stretching  has  been  followed  by  complete  relief  for  a  time, 
but  so  far  the  reports  upon  this  method  do  not  seem  to  indicate  any 
better  results  than  are  obtained  by  simple  section  of  the  nerve. 
Andrews  reports  a  case  in  which  stretching  of  the  stump  and  tearing 
awav  of  the  cicatrix  in  a  case  of  neuralgia  of  the  inferior  maxillary 
division  upon  which  he  had  operated  one  and  a  half  years  before  by 
excision  with  complete  relief,  but  in  which  the  pain  had  again  become 
severe,  was  completely  successful  in  abating  the  trouble. 

Evulsion  is  sometimes  productive  of  better  results  than  excision, 
as  many  times  a  longer  section  of  the  nerve  can  be  removed  than  by 
cutting  it  with  a  knife  or  neurotome.  This  method  consists  of  grasp- 
ing the  nerve — after  it  has  been  separated  from  its  vessels — as  far 
back  as  possible,  with  hemostatic  forceps,  and  forcibly  tearing  it  away. 


AI'.Ml-.XI'    Ol'     lUl  l-"AtJ.\I.    NKIKALC.IA. 


415 


Si(bcufa)icoiis  Diz'ision  of  the  Supraorbital  Nerve  is  accomplished 
by  entering-  a  tenotome  knife  between  the  eyebrows  midway  between 
the  nerve  and  tlie  median  line,  and  passing  horizontally  beneath  the 
skin  until  its  point  is  beyond  the  nerve;  its  edge  is  then  turned  back- 
ward and  pressed  against  the  bone,  and  the  nerve,  lying  between  it 
and  the  bone,  is  divided  by  withdrawing  the  knife.  Or,  the  knife  may 
be  entered  at  the  same  point,  but  passed  close  to  the  bone  instead  of 
just  under  the  skin,  its  edge  turned  downward  toward  the  margin  of 
the  orbit,  and  the  nerve  divided  by  sweeping  the  knife  downward 
across  the  mouth  of  the  supraorbital  foramen.     (Stimson.) 


A,  B,  Incisions  for  Excisionof  the  Supraorbital  Nerve  ;  C,  Incision  for  Excision  of  the  Infraorbital 
Nerve,  after  the  method  of  Tillaux. 

Excision  of  the  Supraorbital  Nerve  may  be  made  through  incisions 
above  or  below  the  eyebrow.  When  made  above,  the  incision  may  be 
an  inch  long  and  parallel  to  the  eyebrow,  with  its  center  directly  over 
the  supraorbital  notch  or  foramen.  (Fig.  152,  A.)  The  incision  is 
carried  down  to  the  bone,  the  distal  end  of  the  nerve  seized  with  for- 
ceps, dissected  out,  and  excised. 

The  incision  made  below  the  eyebrow  requires  the  eyebrow  to  be 
drawn  up,  and  the  eyelid  down,  so  as  to  make  the  tissues  tense.  An 
incision  is  then  made  close  to  the  lower  edge  of  the  supraorbital  arch, 
an  inch  long,  through  the  skin,  orbicularis  muscle,  and  tarsal  ligament. 
(Fig.  152,  B.)  The  nerve  is  then  traced  backward  from  the  notch  as 
far  as  necessary  by  depressing  the  eyeball  and  the  levator  palpebrse  with 
a  spatula,  and  dividing  the  nerve  with  curved  scissors. 

Excision  of  the  Superior  Maxillary  Nerve  is  made  by  ,a  curved  in- 
cision about  an  inch  and  a  half  long  following  the  lower  border  of  the 
orbit;  a  second  incision  at  right  angles  to  the  first,  one  inch  in  length, 


4l6  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

is  next  made  upon  a  line  drawn  from  the  supraorbital  notch  to  the 
mental  foramen,  which  will  intersect  the  infraorbital  foramen  and 
expose  the  nerve.  (Fig.  152,  C. )  A  silk  thread  is  now  passed  beneath 
the  nerve  and  tied  for  the  purposes  of  identification  and  traction.  The 
orbital  tissues  are  then  lifted  by  dissecting  up  the  periosteum  from  the 
floor  of  the  orbit,  and  elevated  with  a  spatula;  the  infraorbital  canal 
found  and  broken  through,  the  nerve  isolated  and  lifted  from  its  bed 
with  a  curved  hook,  and  divided  with  curved  scissors  at  a  point  as  far 
back  in  the  orbit  as  possible.  Traction  upon  the  ligature  will  draw  the 
nerve  from  its  canal,  when  it  may  be  severed  below  the  ligature.  Hem- 
orrhage is  rarely  troublesome,  though  occasionally  it  may  be  necessary 
to  use  a  little  packing  to  control  the  hemorrhage  within  the  orbit.  Fig. 
153  shows  scar  resulting  from  two  different  operations  for  infraorbital 
neuralgia;  A,  Liicke's  operation;  B,  Tillaux's  operation. 

Removal  of  Meckel's  Ganglion. — This  operation  is  sometimes  un- 
dertaken after  the  removal  of  the  superior  maxillary  nerve.  This  is 
done  by  an  operation  devised  by  Carnochan,  which  consists  of  a  T- 
shaped  incision  below  the  orbit,  the  horizontal  line  reaching  from  can- 
thus  to  canthus,  and  the  vertical  one  nearly  to  the  mouth;  the  tissues 
are  dissected  from  the  facial  surface  of  the  bone,  and  the  infraorbital 
nerve  found  and  secured  with  a  ligature.  The  outer  wall  of  the  antrum 
is  next  perforated  with  trephine  or  chisel,  the  infraorbital  foramen 
being  included.  The  posterior  wall  of  the  antrum  is  also  perforated  in 
the  same  manner,  care  being  taken  not  to  wound  the  internal  maxillary 
artery,  which  lies  immediately  behind  and  in  close  relation  to  the  bone. 
The  groove  in  the  floor  of  the  orbit  is  next  broken  "through,  and  after 
dividing  the  nerve  upon  the  cheek  it  is  drawn  down  and  through  the 
perforation  in  the  posterior  wall  of  the  antrum.  Tension  upon  the 
nerve  offers  a  sure  guide  to  the  ganglion,  by  tracing  it  back  into  the 
spheno-maxillary  fossa,  and  to  the  foramen  rotundum,  where  it  may 
be  divided  by  long,  slender,  curved  scissors.  Hemorrhage  may  be 
controlled  with  gauze  or  sponges  fastened  to  sponge-holders.  For  the 
purpose  of  illuminating  the  deeper  portions  of  the  wound  an  electric 
light  or  a  head  mirror  are  absolutely  necessary. 

Excision  of  the  Inferior  Maxillary  Nerve. — This  nerve  may  be 
divided  in  three  locations,  at  its  exit  from  the  mental  foramen,  in  the 
canal,  and  before  its  entrance  into  the  canal. 

Excision  at  the  Mental  Foramen. — This  is  accomplished  within  the 
mouth  by  an  incision  in  the  gingivo-labial  fold  above  the  foramen, 
which  is  located  just  behind  the  root  of  the  first  bicuspid  tooth.  The 
soft  parts  are  dissected  from  the  bone  with  an  elevator  or  periosteo- 
tome,  until  the  nerve  is  reached,  which  is  usually  about  an  inch  or 
an  inch  and  a  quarter  below  the  tip  of  the  cuspid  tooth.  The  nerve 
may  then  be  seized  with  forceps  and  drawn  as  far  from  the  canal  as 


TREATMENT    OF    TRIFACIAL    NEURALGIA. 


417 


possible,  and  divided  with  scissors  close  to  the  bone,  and  upon  the 
peripheral  side  close  to  the  soft  tissues. 

Excision  -cvithin  the  Canal.— This  can  be  most  successfully  made  by 
the  Garretson  operation  (Fig.  154,  A),  which  consists  of  making  an  in- 
cision about  two  inches  long  from  the  angle  of  the  jaw  forward.     The 

Fig.  153. 


A,  Incision  for  Liicke's  operation  for  Excision  of  the  Infraorbital  Nerve;  B,  Incision  for  Tillaux 
operation. 


incision  should,  for  cosmetic  reasons,  be  kept  well  under  the  lower  bor- 
der of  the  jaw.  This  incision  will  divide  the  facial  artery,  which  must 
be  secured.  The  tissues  are  now  lifted  from  the  outer  surface  of  the 
bone  by  a  periosteotome,  for  the  entire  length  of  the  incision.  The  ex- 
ternal plate  of  the  jaw  is  next  trephined  at  the  opposite  ends  of  the  in- 
cision, and  about  a  quarter  of  an  inch  above  the  lower  border  of  the 

28 


4i8 


SURGERY    OF    Til  li    FACE,    MOUTH,    AND    JAWS. 


jaw;  the  perforations  made  by  the  trephine  are  next  united  by  two 
parallel  incisions  in  the  bone  by  a  small  circular  saw,  revolved  by  the 
surgical  engine, — the  trephine  is  driven  by  the  same  power, — when 
with  an  elevator  the  section  of  bone  can  be  lifted  from  its  place,  thus 
exposing  the  inferior  dental  nerve  and  vessels  lying  in  the  canal.  The 
nerve  is  then  isolated  and  lifted  from  its  bed  with  a  blunt  hook,  and  a 
section  removed.  Care  should  be  taken  not  to  wound  the  artery,  as 
hemorrhage  is  sometimes  troublesome.  Agnew's  operation  consists 
of  trephining  the  jaw  at  the  angle  directly  over  the  canal  (Fig.  154,  B), 
and  removing  a  section  of  the  nerve. 

Fig.  154. 


A,  Garretson  operation  ;  B,  Agnew  operation  ;  C,  Pancoast  operation;  D,  Cryer  operation. 

(After  Cryer.) 

Excision  before  its  entry  into  the  canal  may  be  made  either  through 
the  mouth  or  through  the  cheek. 

In  operating  through  the  mouth,  the  jaws  must  be  extended  as  far 
as  possible  with  a  mouth-gag  placed  upon  the  opposite  side  (Fig. 
155).  The  mucous  membrane  is  first  incised  at  a  point  on  the  anterior 
border  of  the  ascending  ramus,  midway  between  the  crowns  of  the 
upper  and  lower  second  or  third  molar  teeth,  while  the  jaws  are  in  this 
extended  position.  The  finger  is  next  inserted  between  the  internal 
pterygoid  muscle  and  the  ramus.  The  tubercle  situated  at  the  opening 
of  the  foramen  is  now  felt  (Fig.  156,  S)  ;  and  the  nerve  brought  to  the 
surface  by  means  of  a  blunt  hook,  grasped  with  hemostatic  forceps,  and 


TREATMENT    OF   TRIFACIAL    NEURALGIA. 


419 


a  section  removed.  Hemorrhage  is  sometimes  profuse.  Care  must  be 
exercised  not  to  mistake  the  long  internal  lateral  ligament  for  the  nerve. 
Pancoast  performed  excision  of  the  nerve  by  first  removing  the 
coronoid  process  by  an  incision  through  the  cheek  (Fig.  154,  C). 
There  is  a  serious  objection  to  this  operation,  for  the  reason  that  it 
destroys  the  use  of  the  temporal  muscle. 

Fig.  155- 


Mason  Gag. 


In  operating  through  the  cheek  by  an  external  incision,  after  the 
method  of  Cryer,  an  incision  is  made  over  the  center  of  the  ramus, 
beeinnine  at  the  zvgomatic  arch  and  extending  downward  an  inch  and 


Fig.  156. 


The  Inferior  Maxillary  Bone— Internal  Surface  of  the  Right  Side. 
G,  Genial  tubercles  ;  M,  Mylo-hyoid  ridge;  O,  opening  of  the  inferior  dental  canal ;  H,  Mylo-hyoid 
groove  ;  S,  Pterygoid  tubercle  ;  A,  Anterior  or  coronoid  process  ;  P,  Posterior  or  condyloid  process. 

a  half;  the  semilunar  notch  is  now  exposed  and  deepened  with  surgi- 
cal burs  to  the  depth  of  about  one  inch,  when  the  opening  thus  made 
through  the  bone  exposes  the  nerve.  (Fig.  154,  D.)  It  is  now  picked 
up  and  a  section  removed.  The  wounds  are  to  be  sutured,  and  if 
treated  with  antiseptic  precautions,  will  commonly  unite  by  first  inten- 
tion. 


CHAPTER    XLIII. 

CONGENITAL  FISSURES  OF  THE  LIP  AND  THE  VAULT  OF  THE 

MOUTH. 

Fissures  of  the  upper  lip,  superior  maxillary  bones,  and  soft  pal- 
ate are  the  result  of  arrested  development  of  the  parts  involved,  and 
consequent  failure. of  these  parts  to  form  a  junction  and  coalesce.  The 
fissure  may  be  of  any  degree  from  a  slight  notch  in  the  lip  or  a  bifurca- 
tion of  the  uvula,  to  a  complete  cleft  of  the  lip,  alveolar  process,  palate 
bones,  and  velum  palati;  or  a  double  cleft  of  the  lip  and  bony  palate  and 
almost  entire  absence  of  the  velum. 

The  slightest  degree  of  fissure  is  represented  by  a  superficial  notch 
or  scar  in  the  upper  lip,  and  by  a  mere  suggestion  of  a  bifurcation  of 
the  uvula.  The  most  common  forms  are  fissures  of  the  lip  and  the 
velum.  Fissures  of  the  lip  often  occur  without  cleft  of  the  velum  or 
maxillary  bones,  while  on  the  other  hand  cleft  of  the  velum  frequently 
occurs  without  fissure  of  the  lip ;  the  cleft  in  the  palate  may  even  extend 
forward  to  the  alveolar  process,  and  still  not  be  associated  with  a  fissure 
of  the  lip;  but  where  the  fissure  extends  through  the  alveolar  process 
the  writer  has  always  found  it  associated  with  a  fissure  of  the  lip.  'Tn 
some  rare  instances,  however,  the  alveolar  process  alone  may  be  fis- 
sured." 

Fissures  of  the  lip  and  palate  may  be  unilateral  or  bilateral;  but  are 
most  frequently  unilateral,  and  most  commonly  upon  the  left  side. 

Figs.  157  and  158  are  photographs  of  cases  which  have  come 
under  the  care  of  the  writer,  and  are  inserted  for  the  purpose  of  illus- 
trating some  of  the  extremes  in  unilateral  fissures  of  the  lip  and  the 
vault  of  the  mouth. 

In  the  child  (male)  represented  by  Fig.  157,  there  Avas  complete 
cleft  of  the  hard  palate,  velum  palati,  and  right  side  of  the  lip,  with 
marked  protrusion  and  eversion  of  the  intermaxillary  bone;  in  all  other 
respects  the  child  was  perfectly  formed.  No  history  of  hereditary  ten- 
dency or  of  maternal  impressions  could  be  deduced. 

Fig.  158,  also  a  male  child,  has  complete  cleft  of  the  hard  palate, 

velum  palati,  and  left  side  of  the  lip,  with  marked  protrusion  of  the 

intermaxillary  bone.     The  deformity  of  the  face  in  this  case  is  much 

greater  than  in  the  preceding  one,  while  in  other  respects  the  child  was 

420 


CONGENITAL    FISSURES    OF   THE    LIP,    ETC. 


421 


defective  in  development,  having  an  immense  congenital  scrotal  hernia, 
— larger  than  a  goose-egg, — and  the  fourth  and  fifth  toes  of  the  left 
foot  united. 

Bilateral  fissure  of  the  lip  and  maxillary  bones  with  protrusion  of 
the  intermaxillary  bones  and  median  cleft  of  the  soft  palate  occasion- 
ally occurs.  (Fig.  159.)  The  writer  has  operated  ui)on  several  cases 
of  this  character  associated  with  extensive  protrusion  of  the  intermax- 
illary bones.  Figs.  160  and  161  show  a  rather  extreme  case.  In  each  of 
these  cases  there  was  no  union  of  the  palate  process  with  the  vomer  on 
either  side. 

Fig.  157. 


Complete  Cleft  of  the  Hard  Palate,  Velum  Palati,  and  Right  Side  of  the  Lip,  with 
MARKED  Protrusion  of  the  Intermaxillary  Portion  of  the  Jaw.    Child  9  weeks  old. 


In  exceptional  cases  the  fissures  may  extend  upward  on  either 
side  of  the  nose,  or  backward,  involving  the  base  of  the  skull.  Median 
fissure  is  very  rare.  Salter  mentions  three  cases,  one  described  by 
Rokitansky,  one  met  in  his  own  practice,  and  a  specimen  in  the 
Museum  of  the  Royal  College  of  Surgeons,  London.  Occasionally 
there  is  an  entire  absence  of  the  maxillary  bones,  and  consequently 
of  the  incisor  teeth. 

A  case  of  this  character  recently  came  under  the  observation  of 
the  writer  in  a  female  child  six  weeks  old,  in  which  there  was  a  com- 
plete cleft  of  the  hard  and  soft  palates  and  fissure  of  the  lip  on  the  left 
side,  with  entire  absence  of  the  intermaxillary  bone  and  the  vomer. 
The  cleft  through  the  alveolar  process  measured  five-eighths  of  an  inch 
in  width.  The  tip  of  the  nose  was  greatly  depressed,  being  but  very 
slightly  elevated  above  the  level  of  the   cheeks.     The   cartilaginous 


422 


SURGERY    OF   THE    FACE,    MOUTH,   AND   JAWS. 


nasal  septum  was  also  absent.  The  whole  condition  caused  one  of  the 
most  ugly  deformities  imaginable.  There  was  no  history  of  heredity 
or  of  maternal  impression. 

In  Salter's  case  of  median  fissure,  the  right  intermaxillary  bone 
was  slightly  deficient,  with  absence  of  the  central  incisor;  the  lateral, 
however,  was  in  position  standing  close  to  the  cuspid  and  separated 
from  the  left  central  by  a  deep  fissure. 

Fig.  158. 


Complete  Cleft  of  Hard  Palate,  Velum  Palati,  and  Left  Side  of  the  Lip,  with  marked 
Protrusion  of  the  Intermaxillary  Portion  of  the  Jaw.    Child  8  months  old. 


Broca  has  reported  quite  recently  a  case  of  complete  fissure  of  the 
upper  lip  with  absence  of  the  median  tubercle. 

Median  fissure  of  the  face  is  more  often  associated  with  the  lower 
lip  and  inferior  maxilla  than  with  the  upper  portion  of  the  face.  A 
remarkable  case  of  this  character  (Fig.  162)  is  reported  by  A.  Wolfier, 
as  occurring  in  an  infant  that  came  under  his  notice  when  it  was 
twenty-three  days  old,  in  which  the  lower  lip  was  cleft,  the  inferior 
maxilla  separated  upon  the  median  line,  but  held  together  by  a  cica- 
tricial band;  the  fissure  extending  downward  into  the  neck  to  the 


CONGENITAL    FISSURES    OF   THE    LIP,    ETC.  423 

supra-Sternal  fossa;  the  anterior  portion  of  the  tongue  was  Hkewise 
divided  into  two  halves  upon  the  median  line.  These  deformities  were 
successfully  corrected  by  surgical  operations. 

Sometimes  there  are  other  defects  of  development  associated  in 
the   individual   with   fissure   of  the    palate,  due  to  the  same  general 

Fig.  159. 


Double  Hare-Lip, 
with  protrusion  of  the  intermaxillary  bone,  and  non-union  of  the  maxillary  bone  with  the  vomer 
on  both  sides,  making  what  might  be  termed  a  double  cleft  in  the  hard  palate.    The  cleft  m  the  soft 
palate  was  exceedingly  wide,  showing  very  imperfect  development. 

causes.  These  defects  are  occasionally  of  an  extreme  character  and 
serious  nature,  and  interfere  with  the  performance  of  the  natural  func- 
tions of  the  body. 

Origin. The  origin  and  causes  of  hare-lip  and  cleft  palate  are  to 

be  sought  for  among  the  pre-natal  influences,  and  are  generally  con- 
ceded to  be  faults  in  the  developmental  process.  These  influences  to 
be  operative  must  occur  prior  to  the  tenth  week  after  conception.  The 
formation  of  the  maxilla  begins  at  a  very  early  period  of  intra-uterine 


424  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

life,  viz,  at  about  the  twenty-eighth  day,  by  the  development  of  four 
tiny  buds,  tubercles,  or  processes  near  the  central  portion  of  that  sur- 

FlG.    1 60. 


Double  Hare-Lip  with  Protruding  Intermaxillary  Bones.    Side  view. 


Fig.  161. 


Double  Hare-Lip  with  Protruding  Lvtermaxillary  Bones.    Front  view. 


CONGENITAL    FISSURES    OF    THE    LIP,    ETC. 


425 


face  of  the  nulinicntary  head  which  is  destined  to  form  the  face  (Fig. 
163),  which  are  denominated  the  superior  or  frontal  processes  or  tuber- 
cles,  and   the   lateral   or  oblique    maxillary   processes   or   tubercles. 


Fig.  162. 


Median  Fissure  of  the  Lower  Lip  and  Chin.     (After  Wolfler.) 


Fig.  163. 


Superior  Tubercle. 
Lateral  Tubercle. 


Superior  Tubercle. 
Lateral  Tubercle. 


Head  of  an  early  Human  Embryo,  showing  the  Disposition  of  the  F.\cial  Fissures  and 
OF  the  Superior  and  Lateral  Tubercles.     (After  His.) 


426  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

The  superior  processes  elongate  downward,  and  at  the  same  time 
approach  each  other  toward  the  median  Hne,  where  they  finally 
coalesce  to  form  the  intermaxillary  bones  and  the  central  portion  of  the 
upper  lip.  The  latter  processes  likewise  elongate  and  approach  each 
other  toward  the  median  line,  where  they  finally  meet  the  superior 
processes  and  unite  with  them,  thus  forming  the  lateral  halves  of  the 
superior  maxillary  bone,  palate  bones,  the  cheeks,  and  lateral  portions 
of  the  upper  lip  and  the  velum  palati. 

Non-Union  of  Superior  and  Lateral  Processes. — The  frontal  pro- 
cesses rarely  fail  to  unite  upon  the  median  line;  but  it  is  not  uncommon 
for  the  oblique  maxillary  processes  of  either  side  to  fail  to  unite  with 
the  frontal  processes,  and  occasionally  both  sides  fail;  thus,  in  the 
former  case  producing  a  fissure  upon  the  right  or  left  side,  and  in  the 
latter  a  double  fissure. 

Fissures  of  the  lip  are  the  result  of  the  same  causes,  viz:  failure 
of  the  central  portion  of  the  lip  to  unite  with  the  lateral  portions,  while 
clefts  in  the  velum  palati  are  the  result  of  a  non-union  of  the  lateral  half 
with  its  fellow  upon  the  median  line. 

Arrested  Development. — In  many  cases  there  is  a  deficiency  in 
the  various  tissues  which  go  to  make  up  the  complete  superior  max- 
illary bone,  palate  bones,  lip,  and  soft  palate;  hence  the  primary  cause 
would  seem  to  be  an  arrestment  of  the  developmental  process  in  these 
particular  parts.  The  writer  has  seen  several  cases  in  which  the  velum 
palati  especially  was  very  deficient  and  only  rudimentary  in  character, 
while  in  others  there  was  a  marked  deficiency  in  all  of  the  tissues  of 
these  parts,  leaving  a  broad,  yawning  aperture. 

The  extent  of  the  fissure  will  depend  very  largely,  if  not  entirely, 
upon  the  time  at  which  the  arrestation  of  development  occurred;  the 
earlier  the  period  the  more  extensive  the  cleft,  and  vice  versa. 

At  about  the  fortieth  day  after  conception  the  superior  and  lateral 
processes  have  united,  and  by  the  end  of  the  tenth  week  the  vault  of  the 
mouth  has  been  completed  by  the  union  of  the  velum  palati  and  uvula 
through  their  entire  length;  this  process  begins  at  the  anterior  aspect, 
and  progresses  backward,  the  uvula  being  the  last  portion  to  unite. 

In  certain  cases  of  hare-lip  and  cleft  palate  there  is  a  sufficiency 
of  tissues,  the  only  fault  seemingly  being  a  failure  of  union  of  the  parts 
at  the  proper  time.  These  cases  when  treated  surgically  in  the  early 
months  of  infanc3%  generally  secure  normal  position  of  the  parts  and 
a  complete  restoration  of  function. 

The  fundamental  influences,  however,  which  underlie  the  causa- 
tion of  these  defects  in  development  have  not  yet  been  reached,  and  all 
theories  which  have  so  far  been  advanced  to  account  for  them  belong 
to  the  realm  of  speculation  and  conjecture. 

Faulty  Nutrition. — Some  have  thought  the  trouble  to  be  caused 


CONGENITAL    FISSURES    OF    THE    LIP,    ETC.  427 

by  a  fault  in  the  diet,  through  the  exclusion  of  meat  as  an  article  of 
food,  or  the  introduction  of  an  insufficient  quantity  of  calcium  phos- 
phates into  the  system  of  the  mother  during  gestation. 

As  an  argument  in  favor  of  this  view  it  might  be  stated  that 
the  lions  in  the  Zoological  Gardens  of  London  were  fed  for  several 
years  upon  meat  from  large  animals  having  bones  too  large  for  them 
to  crusli  and  swallow;  this  was  followed  by  the  birth  of  cubs  with  cleft 
palate, — 99  per  cent., — which  lived  but  a  short  time  on  account  of  their 
inability  to  suckle.  The  lions  were  then  occasionally  given  a  small 
animal,  like  a  goat  or  sheep,  the  bones  of  which  were  readily  crushed 
by  their  teeth,  and  the  young  afterward  born  had  perfectly  formed 
palates. 

At  the  Zoological  Garden  of  Dublin  a  like  experience  was  en- 
countered, and  was  counteracted  by  feeding  the  pregnant  lions  with 
ground  bones  and  foods  containing  calcium  phosphates.  Dr.  J.  Ewing 
Mears  reports  the  same  condition  prevailing  among  the  offspring  of 
the  lions  at  the  Philadelphia  Zoological  Garden. 

Neither  of  these  arguments  is  entitled  to  very  much  weight,  for 
the  reason  that  it  is  a  fairly  well-established  fact  that  union  of  the 
superior  and  lateral  maxillary  processes  in  the  human  subject  is  not 
dependent  upon  ossification  of  these  structures,  for  union  or  coales- 
cence takes  place  in  advance  of  ossification,  and  this  process  is  not 
completed  along  the  line  of  the  sutures  until  some  time  after  birth. 

It  is  also  a  well-established  physiologic  law  that  in  the  pregnant 
woman,  if  there  is  not  a  sufficient  amount  of  calcium  salts  ingested  to 
support  the  extra  demands  made  upon  the  system  for  the  proper  devel- 
opment of  the  osseous  framework  of  the  fetus,  and  to  recoup  the  waste 
in  her  own  tissues,  the  material  already  stored  up  in  her  body  is  drawn 
upon  to  supply  the  demands  of  the  fetus. 

Changes  in  the  constituent  elements  of  the  bones  are  of  common 
occurrence  as  a  result  of  malnutrition.  Dalton  says,  "Next  to  the 
chlorid  of  sodium,  the  phosphate  of  calcium  is  considered  the  most 
important  ingredient  of  the  body.  It  is  met  with  universally  in  every 
tissue  and  every  fluid,"  and  "whenever  the  nutrition  of  the  bone  during 
life  is  interfered  with  from  any  pathologic  cause,  so  that  its  phosphate 
of  calcium  becomes  deficient  in  amount,  a  softening  of  the  osseous 
tissue  is  the  consequence,  by  which  the  bone  yields  to  external  pres- 
sure and  becomes  more  or  less  distorted." 

In  fractures  occurring  during  gestation,  union  is  often  delayed, 
sometimes  until  after  delivery.  Padieu  describes  a  case  in  which  frac- 
tures of  the  tibia  and  fibula  occurred  nine  days  after  the  suppression  of 
the  menses,  and  in  which  union  was  delayed  until  the  end  of  gestation. 
The  process  of  union  began  ten  days  after  delivery,  and  was  completed 
at  the  end  of  a  month. 


.  428         SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 

The  pelvis,  though  looked  upon  at  all  other  times  as  a  compara- 
tively solid  framework,  frequently  becomes  relaxed  in  its  articulations 
during  pregnancy,  so  that  the  sacro-iliac  and  pubic  joints  become 
movable. 

Many  women  are  in  the  habit  of  discarding  from  their  aliment 
during  pregnancy  all  those  foods  which  contain  an  abundance  of  cal- 
cium salts,  and  restrict  themselves,  as  nearly  as  possible,  to  a  fruit  diet, 
believing  that  by  such  practice  the  bones  of  the  child  will  be  imper- 
fectly calcified,  and  thus  parturition  be  robbed  of  much  of  its  sufifering. 
There  is,  however,  no  scientific  evidence  that  such  a  result  is  obtained, 
while  on  the  other  hand,  as  in  those  cases  affected  with  hyperemesis, 
though  the  child  when  born  may  be  small  and  much  emaciated,  it  has 
the  appearance  of  being  properly  formed,  and  its  bones  as  dense  as  in 
the  majority  of  normal  pregnancies. 

Heredity. — The  question  of  hereditary  influence  is  one  that  calls 
for  more  than  a  passing  notice,  for  a  priori  it  would  strike  one  as  likely 
to  be  an  important  factor  in  the  production  of  defects  of  development. 
The  facts,  however,  which  have  been  adduced  are  not  of  sufficient 
strength  to  establish  it. 

A  few  isolated  instances  have  been  reported  in  which  there  seemed 
to  be  an  indirect  inherited  tendency  in  a  certain  family  to  produce 
offspring  with  hare-lip  and  cleft  palate. 

Oakley  Coles  mentions  two  families  in  which  there  was  a  marked 
tendency  in  this  direction.  In  the  first  family  there  were  three  with 
cleft  palate,  one  seventeen  years  of  age,  another  thirty,  and  the  third 
thirty-five;  the  first  and  last  were  women.  The  man,  who  is  married, 
has  a  family  without  a  single  instance  of  the  father's  deformity.  The 
second  family  was  composed  of  five  children,  two  of  whom  had  fis- 
sure of  the  lip  and  palate;  the  first  child  was  bom  perfect,  the  second 
had  single-  hare-lip  and  cleft  palate,  the  third  child  was  perfect,  the 
fourth  had  double  hare-lip  and  cleft  palate,  and  the  last  child  was 
perfect.     The  maternal  grandmother  also  had  cleft  palate. 

Lawson  Tait  believes  that  heredity  is  a  strong  factor  in  the 
production  of  this  deformity,  and  says  he  has  known  it  to  skip  three 
generations  and  then  appear  in  an  hereditary  form. 

E.  F.  Plicque  reports  a  case  of  hare-lip  in  a  female,  in  which  he 
thinks  the  deformity  is  undoubtedly  inherited.  The  family  history  is 
as  follows:  Both  parents  of  the  patient  were  entirely  free  from  any 
congenital  defect.  One  of  her  father's  brothers  had  supernumerary 
fingers.  A  brother  of  her  mother  was  born  with  hare-lip,  but  both  of 
his  children  were  free  from  the  deformity.  His  sister,  the  mother  of 
the  patient,  has  given  birth  to  nine  children,  five  of  whom  had  hare- 
lip but  no  palatal  defect.  Another  sister  of  the  patient's  mother,  who 
was  free  from  congenital  defect,  gave  birth  to  two  children  with  hare- 


CONGENITAL    FISSURES    OF    THE    LIP,    ETC.  429 

lip  and  cleft  palate  of  an  uncommonly  severe  type.  A  brother  and  a 
sister  of  the  patient,  both  of  whom  had  congenital  hare-lip,  had  mar- 
ried, but  neither  of  their  five  children  had  any  sign  of  the  defect. 

Manley  says  in  all  of  his  cases  there  was  either  a  history  of  heredity 
or  of  maternal  impression. 

The  writer  recently  operated  upon  a  child  six  months  old,  with 
double  fissure  of  the  upper  lip  and  hard  palate,  with  protrusion  of  the 
intermaxillary  bones  and  only  rudimentary  velum,  this  being  the  sec- 
ond child  born  of  the  same  parents,  in  whom  the  tendency  was  marked. 
The  first  child  was  born  with  fissure  of  the  left  side  of  the  upper  lip; 
the  second  child  was  born  perfect,  and  the  third  child  wdth  the  defect 
first  described.  There  was  no  history  of  similar  defects  of  develop- 
ment in  the  family  of  either  of  the  parents. 

Maternal  Impressions. — It  is  interesting  to  note  in  this  connec- 
tion that  most  w^omen  who  are  so  unfortunate  as  to  give  birth  to 
deformed  children,  especially  those  with  deformities  of  the  face  and 
mouth,  feel  very  confident  that  it  is  the  result  of  maternal  impressions 
induced  by  fright,  the  sight  or  knowledge  of  a  like  deformity,  etc. 
How  much,  if  any,  there  may  be  of  scientific  truth  in  this  popular  no- 
tion the  writer  is  not  prepared  to  say,  more  than  that  in  all  popular 
notions  there  is  generally  somewhere  hidden  away  a  kernel  of  truth. 
When  we  know  more  about  the  influence  which  the  nervous  system 
exerts  over  cell-life,  the  effects  of  the  physical  and  mental  conditions 
of  the  parents  at  the  time  of  conception,  and  of  the  female  parent 
during  gestation,  we  shall  be  better  able  to  consider  the  question  from 
a  scientific  standpoint;  till  then  it  would  be  mere  speculation. 

Prognosis. — Most  of  the  fissures  and  perforations  of  the  hard  palate 
are  susceptible  of  radical  cure  by  plastic  surgical  operations;  the  excep- 
tions being  those  cases  where  there  is  marked  deficiency  in  develop- 
ment, or  loss  of  tissue,  and  even  in  these  there  is  reason  to  hope  that 
the  operation  of  transplanting  new  tissue  from  some  adjacent  locality 
will  be  so  perfected  as  to  become  not  only  feasible  as  an  operation,  but 
successful  in  re-establishing  the  functions  of  the  parts.  In  clefts  of 
the  velum  palati  where  the  fissure  is  very  wide  and  the  deficiency  in 
tissue  is  considerable,  it  is  better  to  depend  upon  the  artificial  velum, 
rather  than  to  attempt  a  cure  by  surgical  measures;  for  unless  the 
velum  can  be  restored  to  its  normal  length  so  as  to  perfectly  close  the 
naso-pharyngeal  opening,  the  operation  w^ould  be  a  failure,  from  the 
practical  standpoint,  for  restoration  of  function  is  the  main  object  in 
view. 

The  enthusiasm  of  the  surgeon  has  many  times  carried  him  be- 
yond the  limits  of  a  wise  conservatism  in  the  treatment  of  these  cases, 
especially  in  operations  upon  the  velum,  with  the  natural  result,  failure. 
Consequently  there  are  those  who  decry  all  attempts  at  cure  by  a  surgi- 


430  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

cal  procedure,  and  maintain  that  in  all  cases  mechanical  appliances 
accomplish  the  best  results  in  restoring  the  functions  of  the  parts.  A 
wise  conservatism  in  both  directions  will,  in  the  writer's  opinion,  give 
the  best  results  in  the  individual  case,  for  in  no  department  of  surgery- 
is  good  judgment  of  more  value  to  the  patient. 

The  mortality  of  operations  for  fissure  of  the  lip  and  palate, 
according  to  the  investigations  of  Hoffa,  is  greatly  influenced  by  the 
deformity  itself.  From  the  records  of  114  cases  of  hare-lip,  twenty- 
seven  deaths  occurred,  giving  a  mortality  of  23.7  per  cent. ;  while  out  of 
III  cases  of  complete  fissure  of  the  lip  and  palate  operated  upon,  there 
were  forty-three  deaths,  making  the  mortality  38.73  per  cent. 

Boiling  maintains  that  although  the  mortality  rate  is  high  in  oper- 
ations for  the  correction  of  these  deformities,  it  does  not  very  much 
exceed  that  of  children  of  the  same  age. 

Although  the  writer  has  not  statistics  at  hand  to  substantiate  his 
opinion  upon  this  question,  he  yet  feels  sure  that  this  rate  of  mortality 
is  considerably  higher  than  for  such  operations  among  American 
surgeons. 


CHAPTER    XLIV. 

CONGENITAL  FISSURES  OF  THE  LIP  AND  THE  VAULT  OF  THE 

MOUTH  (Continued). 

Surgical  Treatment. 

The  operations  which  are  practiced  for  closing  the  fissures  of  the 
palate  are  designated  as  uranorrhaphy  and  staphylorrhaphy.  Uranoplasty 
or  uranorrhaphy  is  the  operation  for  closing  a  fissure  in  the  hard  or 
bony  palate,  while  staphyloplasty  or  staphylorrhaphy  is  the  term  ap- 
plied to  the  operation  for  closing  a  cleft  in  the  soft  palate  or  velum 
palati.  Chiloplasty  or  chilorrhaphy  is  the  operation  for  closing  a  fis- 
sure in  the  lip. 

Lemonnier,  a  French  dentist,  is  credited  with  having  been  the  first 
to  suggest  and  to  successfully  operate  for  the  closure  of  fissures  of  the 
palate  by  surgical  operation,  the  record  having  been  published  in  1766. 
Lemonnier  succeeded  in  closing  a  fissure  in  both  the  hard  and  soft 
palates,  by  paring  the  edges  of  the  cleft  with  a  knife,  and  approximating 
them  by  the  use  of  sutures.  Perforations  in  the  hard  palate  he  success- 
fully closed  by  exciting  granulation  of  their  borders. 

Eustache,  a  physician  of  Beziers,  in  1799  recommended  the  same 
procedure  to  a  patient  for  whom  the  day  before  he  had  split  the  soft 
palate  for  the  purpose  of  removing  a  polypus  of  the  pharynx.  The 
operation,  however,  was  declined  by  the  patient.  In  1800  he  pre- 
sented a  paper  upon  the  subject  of  closing  congenital  fissures  of  the 
soft  palate  to  the  Academic  de  Chirurgie  at  Paris,  asking  their  approval 
of  the  operation,  but  this  they  declined  to  grant. 

Von  Graefe  revived  the  operation  in  18 16,  and  reported  to  the 
Medico-Chirurgical  Society  of  'Berlin  that  after  many  unsuccessful 
efforts  to  close  fissures  of  the  soft  palate  he  had  at  last  obtained  success 
by  freshening  the  edges  by  the  application  of  muriatic  acid  and  the 
tincture  of  cantharides,  and  then  approximating  them  with  sutures. 

The  operation  was  modified  by  Roux,  in  18 19,  who  closed  a 
fissure  of  the  palate  by  paring  the  edges  and  applying  sutures. 

Warren,  of  Boston,  in  1820,  being  ignorant  of  the  efforts  of  the 
other  surgeons,  performed  successfully  a  similar  operation.  After  this 
time  the  operation  became  generally  known  and  practiced. 

To  Sir  William  Fergusson,  of  England,  however,  belongs  the 

431 


432  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

credit,  more  than  to  any  other  surgeon,  of  first  demonstrating  and  giv- 
ing to  the  world  a  scientific  basis  for  the  requirements  of  the  operation 
of  staphylorrhaphy. 

The  first  important  question  in  relation  to  the  surgical  treatment 
of  cleft  palate  is  that  of  the  age  of  the  child  which  gives  the  best  pros- 
pect of  a  successful  issue  of  the  operation,  and  the  restoration  of  the 
parts  to  normal  function. 

Experience  has  taught  the  writer  that  skillful  operations  for  clos- 
ure of  fissures  of  the  palate  Avhen  performed  during  the  early  months 
of  infancy  are  more  successful  in  restoring  the  functions  of  deglutition 
and  articulation  than  when  postponed,  as  is  generally  advised,  until 
after  the  eruption  of  the  deciduous  teeth,  or  even  to  as  late  a  period  as 
the  fifteenth  year.  In  order  to  obtain  the  best  results,  the  operation 
should  be  completed  before  the  child  begins  the  first  attempt  at  articu- 
late speech.  When  delayed  until  after  speech  has  been  acquired,  it  is 
much  more  difficult  to  overcome  the  peculiar  nasal  tone  that  always  ac- 
companies the  voice  in  persons  with  perforations,  or  clefts,  of  the  bony 
palate  or  velum.  Another  argument  in  favor  of  early  operation  is  the 
facility  and  comparative  safety  with  which  infants  can  be  brought 
under  the  control  of  anesthetics,  and  the  ease  with  which  anesthesia  can 
be  maintained,  and  this  is  a  great  desideratum  in  all  operations  upon  the 
mouth.  Chloroform  has  the  preference,  with  the  writer,  for  operations 
upon  little  children.  In  complete  clefts  of  the  upper  lip  and  maxilla 
there  is  a  noticeable  broadening  of  the  face  upon  the  affected  side ;  the 
distance  from  the  median  line  of  the  apex  of  the  nose  to  the  antero- 
inferior angle  of  the  malar  bone  is  greater  than  upon  the  perfect  side, 
and  there  is  also  accompanying  this  a  decided  spreading  out  and  flatten- 
ing of  the  ala  of  the  nose.  When  the  lip  has  not  been  closed  this  broad- 
ening of  the  face  and  flattening  of  the  ala  of  the  nose  increase  with  the 
growth  of  the  individual.  (Fig.  164.)  On  the  other  hand,  in  those 
cases  where  the  lip  has  been  closed  early,  this  widening  is  not  only  pre- 
vented, but  there  seems  to  be  a  slight  narrowing  of  the  cleft,  due  no 
doubt  to  the  muscular  contraction  of  the  united  lip.  An  early  operation 
should  therefore  be  recommended  for  the  closure  of  the  lip  and,  where 
the  strength  of  the  child  will  permit,  of  the  fissure  in  the  bony  palate 
and  velum  as  well,  provided  the  condition  of  the  velum  gives  promise  of 
successful  restoration  of  function.  A  second  operation  for  the  closure 
of  the  velum  can  be  done  a  few  months  later  if  the  condition  of  the  child 
is  not  favorable  for  such  procedure  at  the  time  of  closing  the  fissure  in 
the  hard  palate. 

Operations. — In  operations  about  the  mouth  the  choice  of  anes- 
thetics must  be  governed  by  the  age  of  the  patient  and  the  general  con- 
ditions of  health.  Under  no  circumstances  should  general  anesthetics 
be  administered  for  this  operation  if  the  patient  is  suffering  from  acute 


CONGENITAL    FISSURES    OF    THE    LIP,    ETC. 


433 


nephritis  or  Bright's  disease.     Chloroform  is  the  pleasantest  for  all 
mouth  surgery,  especially  in  operations  upon  the  velum,  on  account  of 

Fig.  164. 


Hare-Lip  and  Cleft  Palate. 


Fig.   165. 


Chloroform  Inhaler  and  Drop-Bottle. 


the  fact  that  it  is  not  so  liable  to  cause  vomiting  or  irritation  of  the 
bronchial  mucous  membrane  as  is  ether,  though  it  has  the  disadvantage 

29 


434 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


of  being  much  more  dangerous  to  life.  Little  children,  however,  as  a 
rule,  bear  chloroform  much  better  than  adults,  and  it  may  therefore  be 
administered  with  comparative  safety,  and  also  much  better  after- 
effects. A  most  convenient  method  of  administering  chloroform  is  by 
use  of  the  inhaler  and  drop-bottle  (Fig.  165),  though  it  may  be  admin- 
istered upon  a  handkerchief  or  a  napkin.  When  administering  ether, 
the  inhaler,  Figs.  166  and  167,  will  be  found  most  convenient  and  useful. 


Fig.  166. 


Ether  Inhaler. 

Fig.  16; 


Ether  Inhaler. 

The  position  of  the  patient  in  operations  upon  the  vault  of  the 
mouth  is  one  that  needs  careful  consideration,  on  account  of  hemor- 
rhage, which  is  often  quite  profuse  when  operating  upon  the  hard 
palate  by  the  Langenbeck  method,  and  the  difficulties  sometimes  ex- 
perienced in  getting  good  illumination  of  the  parts.  The  position 
shown  in  Fig.  168  is  the  best  under  nearly  all  circumstances,  as  it  per- 
mits the  blood  to  escape  by  the  nostrils  instead  of  into  the  throat,  and 
at  the  same  time  gives  a  good  view  of  the  parts  if  the  operator  stands 
at  the  head  of  the  patient. 

The  instruments  needed  in  performing  a  staphylorrhaphy  are:  a 


CONGENITAL    FISSURES    OF   THE    LIP,    ETC. 


435 


mouth-gag,  Mason's  (Fig.  155)  or  Whitehead's  (Fig.  169),  a  sharp- 
pointed  curved  bistoury  (Fig.  170),  a  pair  of  mouse-tooth  tissue-forceps 
(Fig.  171),  a  pair  of  curved  needles — right  and  left — with  handles 
(Fig.  172),  a  suture  pick-up  (Fig.  173)  and  a  wire-twister  (Fig.  174), 
a  pair  of  small,  long-handled  scissors,  silk  and  silver  wire  sutures,  per- 
forated shot,  and  a  shot  compressor. 

Fig.  168. 


■ill ,. 


Position  of  Head  during  Opkrations  on  the  Mouth. 


Fig.  169. 


Whitehead  Gag. 


In  operating  upon  a  simple  hare-lip,  a  bistoury  or  the  hare-lip 
scissors  may  be  used  for  paring  the  edges  of  the  cleft.  (Fig.  175.)  In 
a  flap  operation  upon  the  lip  the  bistoury  or  a  small  scalpel  is  the  best 
for  this  purpose.  A  pair  of  lip-compressors  (Fig.  176),  will  also  be 
found  serviceable  for  controlling  the  hemorrhage.  The  lip  may  be 
united  either  with  the  hare-Kp  pins  and  the  figure-of-8  suture,  or  wdth 
the  interrupted  suture  of  silk  or  catgut. 


436 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 
Fig.  170. 


Curve-pointed  Staph vlorrhaphv  Bistourv. 

Fig.  171. 


Special  Staphylorrhaphy  Tissue  Forceps. 

Fig.  172. 


Author's  Jackson-Eve  Staphylorrhaphy  Neelles. 

Fig.  173. 


Suture  Pick-up. 

Fig.  174. 


Special  Wire-Twister. 

Fig.  175. 


Hare-Lip  Scissors. 


Fig.  176. 


Lip  Compressors. 


CONGENITAL    FISSURES    OF    THE    LIP,    ETC.  437 

Hare-Lip.^ — In  uniting-  fissures  of  the  lip  it  is  important  to  con- 
serve as  much  of  the  tissue  as  possible,  in  order  that  the  lip  may  not 
be  unnecessarily  contracted.  Various  methods  have  been  devised  to 
give  a  normal  shape  to  the  free  border  of  the  lip  and  to  prevent  the 
notched  condition  which  so  often  follows  hare-lip  operations. 

In  all  operations  for  closing  fissures  of  the  lip  it  is  important  to 
dissect  the  lip  from  the  alveolar  process  upon  either  side  of  the  cleft 
for  a  considerable  distance  backward,  in  order  to  gain  as  much  tissue 
as  possible  and  to  prevent  strain  upon  the  freshly-united  edges  of  the 
cleft. 

The  common  method  of  uniting  a  cleft  in  the  lip  is  simply  to  pare 
the  edges  with  a  curved  bistoury,  inserting  it  at  the  angle  of  the  cleft 
upon  one  side  and  then  upon  the  other,  and  carrying  it  through  the  lip 
to  the  vermilion  border,  removing  a  paring  the  full  thickness  of  the  lip, 
or  obtaining  the  same  result  by  trimming  the  edges  with  the  hare-lip 
scissors.  The  edges  are  then  brought  together  with  sutures  of  silk, 
catgut,  or  hare-lip  pins.  The  lip-compressor  may  be  necessary  to  con- 
trol the  hemorrhage  from  the  coronary  arteries  until  the  sutures  are 
ready  to  be  placed.     Tying  of  these  vessels  is  rarely  if  ever  necessary. 

Fenger,  of  Chicago,  has  lately  devised  a  new  operation  for  hare- 
lip, which  consists  essentially  of  utilizing  the  parings  of  the  fissure  to 
lengthen  the  border  of  the  lip,  splitting  the  edges  of  the  flaps  and  unit- 
ing the  edges  of  the  mucous  membrane  and  the  skin  by  separate  lines 
of  sutures,  this  part  being  similar  to  the  operation  of  Tait  for  uniting 
the  lacerated  perineum,  and  also  that  of  Marcy  for  closing  the  velum 
palati. 

Fillebrown,  of  Boston,  recommends  the  following  operation, 
which  is  similar  to  that  devised  by  Nelaton,  for  relieving  the  notched 
condition  of  the  lip  so  frequently  seen  in  the  border  after  operation  for 
single  fissure  of  the  lip: 

"A  male,  aged  thirty,  a  patient  in  the  Harvard  Dental  Hospital, 
came  to  have  an  obturator  constructed  for  cleft  palate.  The  cleft  in- 
volved the  hard  as  well  as  the  soft  palate,  and  originally  a  hare-lip. 
The  lip  had  been  operated  on,  and  of  course  much  improved,  but  the 
characteristic  notch  was  present.     (Fig.  177.) 

"It  had  long  been  my  belief  that  this  deformity  could  be  remedied, 
and  I  hailed  with  pleasure  the  opportunity  to  apply  the  remedy. 

"The  operation  performed  for  it  is  shown  in  the  illustration  here 
presented.  It  was  the  result  of  study,  experiment,  advice,  and  acci- 
dent, and  its  success  entirely  fulfilled  my  expectations  and  hopes. 

"By  comparing  the  two  cuts  and  noting  the  position  of  the 
letters,  the  operation  will  be  fully  understood. 

"The  line  a-b.  Fig.  178,  represents  the  cicatrix  left  by  the  former 
operation.  The  line  c-d  shows  the  line  of  the  incision  transversely 
across  the  lip. 


438 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


"Fig.  179  shows  the  incision  made  vertical  by  drawing  the  hp, 
down  and  inserting  a  suture  and  drawing  the  points  g-h,  representing 
c-d  of  Fig.  178,  close  together.  This  converted  the  horizontal  in- 
cision into  a  vertical  one,  and  lengthened  the  lip  at  that  point  by  just 
the  length  of  the  cut. 

"Fig.  177  shows  the  case  as  photographed  just  previous  to  the 
operation.  The  notch  was  so  considerable  as  to  show  the  patient's 
lateral  incisor  tooth  continually. 

"Fig.  180  shows  the  case  as  photographed  after  the  lip  had  healed. 

"The  approximation  of  the  lips  was  perfect,  and  but  very  little 
narrowing  of  the  red  border  was  perceptible. 


Fig.  177. 


Fig.  178. 

fa 

I 


c  -= 


=»  a 


Fig.  179. 

e 


?  • 


Fig.  180. 


Fillebrown's  Operation. 


"The  excessive  size  of  the  nostril  was  reduced  by  a  V-shaped  in- 
cision, taking  out  a  piece  of  the  wall  of  the  nostril  and  drawing  the 
edges  together.  This  was  entirely  independent  of  the  lengthening  of 
the  lip. 

"The  operation  proved  an  entire  success." 

In  cases  of  single  cleft  of  the  lip  and  palate  the  writer  advises  the 
closing  of  the  lip  as  soon  after  birth  as  the  condition  of  the  child  will 
permit,  and  the  operation  upon  the  bony  palate  and  velum  from  the 
sixth  to  the  twelfth  month. 

In  operating  for  single  hare-lip,  preference  is  given  to  the  Mirault 
method  as  most  likely  to  produce  a  lip  of  normal  length  and  width. 
This  consists  of  bringing  down  a  flap  from  one  side,  sliding  it  across 
the  cleft,  and  attaching  it  to  the  pared  opposite  side.  Fig.  181  is  the 
result  of  a  Mirault  operation  upon  the  child.  Fig.  157,  photographed 
ten  days  after  the  operation.  The  intermaxillary  bone  was  brought 
into  position  by  fracturing  the  bone  upon  the  left  side  and  uniting  the 
edges  of  the  cleft  in  the  maxilla  by  a  wire  suture.  Owen's  operation, 
Figs.  182  and  183,  is  quite  similar,  although  the  incision  for  making  the 
flap  is  carried  into  the  lip  somewhat  deeper.  This  incision  gives  the 
fullness  to  the  lip  where  most  needed. 


CONGENITAL    FISSURES    OF    THE    LIP,    ETC. 


439 


In  closino-  the  hard  palate  in  these  cases  the  writer  prefers  the 
Langenbeck  operation— muco-periosteal  flap— from  the  fact  that  in 
a  majority  of  instances  it  succeeds  in  filling  the  gap  with  osseous 

tissue. 

In  cases  of  double  cleft  of  the  lip  and  palate  with  protrusion  of  the 
intermaxillary  tubercle,  operation  should  be  advised  at  the  earliest 

Fig.  i8i. 


Result  of  Operation  for  Depression  of  the   Intermaxillary  Portion  of  the  Jaw  and 
Closure  of  the  Hare-Lip.    Ten  Days  after  Operation. 

possible  dav,  as  these  children  are  prevented  from  taking  the  breast 
or  even  the  bottle ;  feeding  by  the  spoon  is  therefore  the  only  method 
that  can  be  used,  and  on  account  of  the  difficulty  in  swallowing,  they 
as  a  rule  do  not  obtain  sufficient  nourishment  to  properly  sustain  the 
functions  of  life,  and  as  a  result  many  dwindle  away  and  die.  Early 
correction  of  the  deformity  in  the  anterior  portion  of  the  mouth  is 
therefore  imperative. 


440 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


It  is  customary  with  most  surgeons  in  operating  upon  these  cases 
to  cut  away  the  protruding"  intermaxillary  tubercle  and  close  the  lip 
upon  the  median  line. 

This  certainly  is  the  easier  method,  but  it  is  open  to  serious  ob- 
jections; first,  because  this  portion  of  the  maxilla  contains  the  incisor 


Fig.  182. 


Fig.  18,1. 


Owen's  Operation. 


Owen's  Operation. 


teeth;  second,  because  it  removes  the  bony  column  upon  which  the 
nose  rests;  and  third,  because  it  produces  an  extreme  narrowing  of 
the  face  in  the  incisor  and  cuspid  regions,  with  more  or  less  complete 
stenosis  of  the  nostrils,  a  deformity  which  can  never  afterward  be 
remedied. 

The  preferable  method  is  to  replace  the  intermaxillary  tubercle  by 
removing  an  inverted  V-shaped  section  from  the  vomer,  carrying  the 

Fig.  184. 


Hanesby  Truss. 


tubercle  into  position  and  retaining  it  there  by  a  wire  passed  through 
holes  drilled  in  the  vomer  anteriorly  and  posteriorly,  to  the  point  of 
section,  and  allowed  to  remain  until  union  has  taken  place. 

If  the  lateral  surfaces  of  the  tubercle  now  come  in  contact  with 
the  lateral  halves  of  the  maxilla,  the  occluding  surfaces  should  be 
freshened,  and  one  or  more  fine  silk  sutures  passed  through  the  gum- 
tissue  upon  either  side.  When  the  surfaces  do  not  occlude  and  the 
separation  to  be  overcome  is  not  very  great,  forcible  pressure  can  be 


CONGENITAL    FISSURES    OF    THE    LIP,    ETC.  44I 

made  upon  the  malar  bones  by  the  hands  of  the  operator  until  the 
surfaces  meet,  and  afterward  held  in  position  by  means  of  the  Hanesby 
truss  (Fig-.  184)  or  rubl^er  bandage,  as  suggested  by  Garretson. 

In  closing  the  lip,  it  is  preferable  to  utilize  the  central  portion  if 
it  is  of  sufficient  width  to  admit  the  passage  of  sutures,  rather  than  to 
cut  it  away,  and  unite  the  lip  upon  the  median  line. 

The  Golding-Bird  operation  is  the  one  usually  practiced  by  the 
writer  in  these  cases;  it  consists  in  removing  the  vermilion  border  on 
all  sides,  leaving  the  prolabium  with  straight  edges.  The  lateral 
halves  of  the  lip  are  then  dissected  from  their  attachment  to  the  bone, 
and  pared  to  fit  the  trimmed  prolabium.  In  order  to  obtain  a  suffi- 
cient amount  of  tissue  to  form  a  good  lip,  it  sometimes  becomes  neces- 
sary to  carry  an  incision  around  the  ala  of  the  nose  and  into  the  cheek. 
A  deep  suture  is  passed  near  the  border  of  the  lip,  just  above  the  edge 
•of  the  mucous  membrane,  and  another  at  the  lower  border  of  the  ala 
•of  the  nose  to  give  proper  shape  to  the  nostrils, — it  is  often  impossible 
to  pass  more  than  these, — and  the  edges  of  the  skin  and  mucous  mem- 
brane brought  into  nice  apposition  with  fine  interrupted  silk  sutures. 
To  relieve  tension  and  protect  the  wound  it  is  covered  with  a  collodion 
■dressing,  and  over  this  an  adhesive  strip. 

The  writer  prefers  to  replace  the  maxillary  tubercle  and  close  the 
lip  at  the  same  time.  Operation  upon  the  fissured  palate  should  be 
deferred  till  a  later  period.  This  operation  he  has  performed  several 
times  with  uniformly  good  results.  One  child  was  but  six  days  old, 
but  the  operation  was  borne  well,  and  he  took  the  breast  three  hours 
•afterward.  The  others  were  between  two  and  six  months  old.  Fig.  185 
shows  the  results  in  a  case  of  double  hare-lip  with  protruding  inter- 
maxillary bones,  four  months  after  the  operation,  in  a  child  three  years 
of  age. 

"Uranorrhaphy. — In  operations  upon  the  bony  palate — urano- 
plasty— the  writer  usually  prefers  the  Langenbeck  method,  which  con- 
sists of  first  paring  the  edges  of  the  cleft;  second,  making  an  incision 
through  the  soft  tissues  covering  the  hard  palate  close  to  the  teeth,  and 
lifting  these  tissues  from  the  bone  with  a  curved  periosteotome,  sliding 
them  over  the  fissure,  and  uniting  the  periosteal  surfaces  together  with 
the  cobbler's  stitch  or  suture.  This  method  of  stitching  is  a  modifica- 
tion suggested  by  the  writer,  and  gives  more  satisfactory  results  than 
the  old  method  of  uniting  the  edges  by  the  interrupted  suture. 

Fergusson's  operation  consisted  of  drilling  the  bony  palate  at 
■short  intervals  from  before  backward,  and  then  splitting  it  with  a 
•chisel.  The  edges  of  the  cleft  having  been  previously  pared,  are  then 
■united  by  silver  wire  sutures. 

Billroth  has  recently  modified  the  Langenbeck  operation  for  clos- 
ing fissure  of  the  hard  palate  and  velum,  by  approximating  the  internal 


442 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


wings  of  the  sphenoid.  This  he  accompHshes  by  dividing  the  mucous 
membrane  at  the  sides  of  the  velum,  and  fracturing  the  bone  with  a 
chisel.  The  mucous  membrane  is  then  utilized  to  close  the  cleft.  His 
object  is  to  do  away  with  the  necessity  of  dividing  the  muscles  of  the 
velum,  particularly  the  circular  or  sphincter  muscle  which  surrounds 
the  naso-pharyngeal  opening,  and  which  has  its  anterior  fibers  in  the 
velum  palati. 

Fig.  185. 


Double  Hare-Lip,  with  Protruding   Intermaxillary  Bones.    Four  Months  after 

Operation. 


Rotter,  of  Munich,  describes  an  interesting  case  of  a  child  six: 
years  old,  upon  whom  he  had  operated  previously  by  the  Langenbeck 
method  for  an  uncommonly  wide  fissure;  the  muco-periosteal  flaps  had 
united  upon  the  median  line  by  first  intention  through  their  entire 
length,  but  left  an  opening  upon  the  left  side  near  the  teeth,  about  four- 
tenths  of  an  inch  in  width,  giving  free  communication  between  the 
mouth  and  nasal  cavity.  To  close  this  opening  he  raised  a  flap  of  skin, 
from  the  forehead  (Fig.  186),  having  a  long  pedicle  attached,  and  the 


CONGENITAL   FISSURES   OF  THE   LIP,   ETC. 


445 


gap  in  the  forehead  was  immediately  closed  with  sutures  (Fig.  187). 
He  then  placed  upon  the  raw  surface  of  the  flap  numerous  epidermal 
grafts  after  the  method  of  Thiersch,  placed  the  flap  against  the  fore- 
head with  the  raw  surface  undermost,  and  held  it  in  position  by  a 
bandage. 

At  the  end  of  eight  days  the  grafts  had  taken,  and  the  flap  was 
covered  with  skin  upon  both  sides.  The  next  steps  were  to  lengthen 
the  incision  along  the  right  side  of  the  nose  to  the  cleft  in  the  lip, 
raise  the  right  ala  of  the  nose,  freshen  the  edges  of  the  opening  in  the 
palate,  stitch  the  flap  into  position,  close  the  fissure  in  the  lip,  and  re- 
place the  ala  of  the  nose.     (Fig.  188.) 

Fig.  186. 


Rotter's  Operation  for  Cleft  Palate.     (Afier  Roller.) 


The  case  was  successful,  and  Rotter  exhibited  the  child  two  years 
later  to  the  Congress  of  German  Surgeons.  One  of  the  remarkable 
facts  in  the  case  was  that  though  the  flap  was  covered  upon  both  sides 
with  skin,  the  moisture  in  which  it  was  constantly  bathed  seemed  to 
have  no  deleterious  effect  upon  it. 

Rotter  states  that  only  two  other  cases  are  on  record  in  which 
tissues  had  been  transplanted  for  a  like  purpose  from  other  locations 
than  the  palate  itself,  the  first  by  Blaisus,  the  second  by  Thiersch. 

Davies-Colley  has  also  devised  a  mode  of  operating  for  the  closure 
of  wide  clefts  in  the  hard  palate.  This  operation  consists  in  forming  a 
triangular  muco-periosteal  flap  upon  one  side  of  the  cleft,  while  upon 


444 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


the  Other  side  a  raw  surface  is  prepared  by  raising  and  reflecting"  a 
longitudinal  flap  in  such  a  way  that  it  can  be  turned  over  as  on  a  hinge 
into  the  cleft.  The  first  flap  is  now  implanted  upon  the  second,  bring- 
ing their  raw  surfaces  together  and  suturing  them  in  this  position. 

Another  method  of  closing  a  wide  cleft  in  the  hard  palate  is  that 
suggested  by  T.  Smith,  which  consists  in  raising  muco-periosteal  flaps 
from  the  sides  of  the  vomer,  operating  upon  one  side  at  a  time,  by 
turning  down  the  flap,  leaving  it  attached  at  the  lower  border  of  the 
vomer,  and  suturing  the  edge  of  the  flap  to  the  border  of  the  cleft  which 
had  been  prepared  to  receive  it  by  freshening  its  edge. 


Fig.  187. 


Fig.  li 


Rotter's  Operation  for  Cleft  Palate. 
(After  Rotter.) 


Rotter's  Operation  for  Cleft  Palate. 
(After  Rotter.) 


Brophy,  of  Chicago,  has  recently  devised  a  new  method  of  approx- 
imating the  edges  of  fissure  of  the  palate  which  is  unique  and  original, 
and  for  which  he  claims  a  decided  advantage  over  other  operations. 

The  method  consists  substantially  in  passing  two  double  silver 
wire  sutures  through  the  superior  maxillary  bone,  within  the  mouth; 
the  posterior  one  inserted  just  behind  the  malar  process,  and  high 
enough  to  pass  over  the  palate  plate  of  the  bone,  emerging  at  the  same 
point  upon  the  opposite  side;  the  anterior  one  is  passed  through  the 
bone  just  in  front  of  the  malar  process.  A  lead  button  having  two  eye- 
holes is  threaded  upon  the  wire,  and  the  ends  twisted  together.  The 
edges  of  the  cleft  having  been  previously  freshened,  the  wires  are 


CONGENITAL   FISSURES    OF   THE    LIP,    ETC.  445 

twisted  until  the  edges  of  the  cleft  are  brought  together.  If  the  re- 
sistance is  such  that  the  edges  do  not  readily  approximate,  the  malar 
process  is  divided  on  either  side  by  the  aid  of  a  heavy  scalpel.  The 
edges  of  the  cleft  are  united  by  sutures  in  the  usual  way. 

This  operation  would  seem  to  be  valuable  if  performed  during  the 
early  months  of  infancy,  while  the  bones  are  still  imperfectly  calcified, 
in  those  cases  where  the  deficiency  of  tissue  is  slight  and  the  edges 
of  the  fissure  but  moderately  separated.  Where  the  cleft  is  wide  and 
the  deficiency  of  bony  tissue  considerable,  it  might  succeed  in  closing 
the  defect  in  the  palate;  though  it  would  establish  another  deformity 
equally  grave  in  character,  viz:  partial  or  complete  stenosis  of  the 
nasal  passage  of  the  affected  side.  It  is  to  be  presumed,  therefore, 
that  Brophy  w^ould  not  advise  this  operation,  only  in  selected  cases 
where  this  condition  could  not  result. 

In  the  cases  first  mentioned  it  would  seem  to  have  an  advantage 
over  the  Langenbeck  muco-periosteal  operation;  but  in  fissures  of  any 
considerable  width,  or  in  double  fissure,  the  latter  procedure  would  be 
preferable. 

In  a  case  of  cleft  palate  in  w^hich  the  Langenbeck  as  well  as  the 
Davies-Colley  operation  failed  to  cover  the  immense  congenital  defect, 
Carl  Black  recently  implanted  a  portion  of  the  tongue.  The  ease  wdth 
which  even  extensive  resection  of  the  tongue  is  tolerated  by  carcinoma- 
tous patients  induced  him  to  form  a  lateral  flap  from  the  tongue,  which, 
after  being  turned  and  reflected  near  the  base,  was  united  with  the 
freshened  edge  of  the  cleft  of  the  same  side.  The  gaping  wound-mar- 
gins of  the  side  of  the  tongue  were  then  accurately  united,  and  the 
floor  of  the  mouth  and  the  lingual  angle  were  packed  with  iodoform 
gauze.  During  the  after-treatment  a  mild  solution  of  boric  acid  was 
sprayed  through  the  nostrils  every  fifteen  minutes.  Liquid  diet  was 
given  exclusively.  After  nine  days  the  base  of  the  flap  w^as  severed, 
and  one  w^eek  after,  the  flap  was  united  with  the  opposite  margin  of  the 
cleft  according  to  the  usual  uranoplastic  procedures. 

Staphylorrhaphy. — A  modification  of  Nekton's  operation  for 
bifid  uvula  and  single  hare-lip  has,  in  the  hands  of  the  writer,  given 
good  results  when  applied  to  closing  the  velum  palati.  This  method 
is  especially  adapted  to  those  cases  where  the  cleft  in  the  velum  is  the 
only  oral  defect. 

The  usual  method  is  to  freshen  the  edges  of  the  velum  with  a  bold 
hand — most  surgeons  claiming  that  successful  union  is  more  often 
obtained  by  this  method  than  when  less  tissue  is  cut  away.  This,  so 
far  as  obtaining  good  union  is  concerned,  is  a  self-evident  fact;  but  why 
sacrifice  tissue  w-hen  there  is  generally  so  little  in  the  first  place  to 
operate  upon?  The  main  object  is  to  restore  function,  and  this  can 
only  be  accomplished  by  restoring  the  velum  and  uvula  to  their  proper 


446 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


width  and  length,  so  as  to  insure  a  perfect  occlusion  of  the  naso- 
pharyngeal opening. 

In  paring  the  cleft  by  either  the  bold  or  conservative  method,  the 
parings  are  usually  sacrificed.  B}'  the  method  which  is  now  presented 
the  parings  are  utilized  to  broaden  and  lengthen  the  velum  and  form 
a  new  uvula. 

In  the  act  of  deglutition  the  velum  palati  is  drawn  up  against  the 
walls  of  the  pharynx,  the  base  of  the  uvula  filling  the  depression  upon 
the  median  line  formed  by  the  approximation  of  the  two  sides  of  the 
pharynx,  thus  perfectly  closing  the  naso-pharyngeal  opening  and  pre- 


FlG.    li 


■Cleft  of  the  Soft  Palate.    Showing  Line  of  Incision  in  the  Author's  Modification  of 
NiiLATON's  Operation  for  Bifid  Uvula  applied  to  Cleft  Velum. 


venting  escape  of  food  into  the  nasal  passages  in  the  act  of  swallow- 
ing, and  materially  assisting  in  the  production  of  articulate  speech  by 
preventing  the  escape  of  certain  sounds  through  the  nasal  passages. 

By  the  modified  Nelaton  operation  every  particle  of  tissue  is  saved 
and  carried  to  that  part  of  the  velum  where  it  is  most  needed  to  im- 
prove the  shape,  the  width,  and  the  length.     (Fig.  189.) 

The  method  is  similar  to  that  often  practiced  upon  single  hare- 
lip, viz:  a  curved,  pointed  bistoury  is  inserted  just  above  the  apex  of 
the  cleft,  and  carried  downward  toward  the  uvula  of  one  side,  about 
■one  line  from  the  cleft  at  the  apex,  gradually  increasing  the  distance  as 
the  bistoury  approaches  the  uvula  to  about  two  lines  from  the  edge  of 


CONGENITAL    FISSURES    OF   THE    LIP,    ETC.  447 

the  clelt  and  three  lines  from  the  posterior  border  of  the  vekim.  This 
.incision  is  repeated  upon  the  opposite  side. 

The  apex  of  the  paring  is  then  carried  backward,  and  the  fresh- 
ened edges  of  the  palate,  after  having  been  split  to  the  depth  of  about 
one-fourth  of  an  inch,  are  approximated  and  sutured.  The  object  in 
splitting  the  palate  is  to  gain  a  broader  surface  of  tissue  at  the  edges  of 
the  cleft,  and  thus  increase  the  chances  of  primary  union. 

Three  or  four  sutures  are  usually  inserted,  silver  wire  being  given 
the  preference  as  less  likely  to  induce  suppuration  or  ulceration  about 
the  sutures.  Tension  is  relieved  when  necessary  by  dividing  the  tensor 
palati  muscle  upon  either  side,  but  this  procedure  is  by  no  means 
always  indicated. 

The  after-treatment  consists  in  keeping  the  wound  and  sutures  as 
clean  as  possible  by  swabbing  and  spraying  the  parts  with  the  Thiersch 
antiseptic  solution  at  least  every  two  or  three  hours.  The  sutures  are 
allowed  to  remain  from  four  to  ten  days,  according  to  indications. 


KiNGSLEY's  Artificial  Velum.     (After  Kingsley.) 

Meclianical  Treatment. — The  mechanical  treatment  of  cleft  pal- 
ate by  means  of  artificial  vela  has  through  the  inventive  genius  of  Dr. 
Norman  W.  Kingsley  been  brought  to  a  very  high  degree  of  perfec- 
tion. In  no  department  of  mechanical  surgery  has  a  greater  achieve- 
:ment  been  recorded  than  in  the  invention  of  the  artificial  flexible  velum. 
All  efforts  in  the  direction  of  mechanisms  for  closing  congenital  defects 
in  the  palate  which  preceded  the  apparatus  of  Kingsley  were  crude, 
clumsy,  rigid  aflfairs,  and  of  but  little  practical  utility  to  the  patient. 
The  discovery  by  Goodyear  of  the  process  of  vulcanizing  rubber  made 
it  possible  for  Kingsley  to  construct  an  appliance  from  a  material 
which  by  its  adaptability  could  be  readily  formed  in  moulds  made  from 
.accurate  impressions  of  the  defective  parts,  and  adjusted  to  them  in 
such  a  manner  as  to  be  free  from  irritation.  The  form  of  the  appli- 
ance is  such  that  it  is  under  complete  control  of  the  muscles  of  the 
parts,  rising  and  falling  with  the  contraction  and  relaxation  of  the 
[levator  palati  muscles,  thus  opening  and  closing  the  naso-pharyngeal 


448 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


Space  and  preventing  the  regurgitation  of  fluids  into  the  nose  and 
making  it  possible  with  proper  training  of  the  vocal  organs  to  attain 
comparatively  perfect  speech.     Fig.   189  represents  a  typical  case  of 

Fig.  191. 


Cleft  Palate  Treated  by  Kingslev's  Artificial  Velum. 


congenital  cleft  of  the  velum  palati.  Fig.  190  shows  the  mechanical 
construction  of  the  velum  and  plate  to  retain  it  in  its  position  in  the 
mouth.     In  Fig.  191  the  velum  is  shown  in  its  position. 


CHAPTER    XLV. 

TUMORS. 

Before  entering  upon  a  description  of  the  tumors  of  the  face, 
mouth,  and  jaws,  it  will  be  of  advantage  to  consider  briefly  the  origin, 
structure,  growth,  character,  and  classification  of  tumors  in  general. 

Definition. — Tumor  (Latin  Tuniere,  to  swell). 

A  tumor  is  an  enlargement  or  swelling  of  a  part.  A  better  defin- 
ition, and  one  more  in  accord  with  the  later  and  stricter  use  of  the 
term,  is  "any  new  growth  not  the  result  of  inflammation  or  hyper- 
plasia." 

In  the  later  classification  of  tumors  by  pathologists,  a  sharp  dis- 
tinction is  drawn  between  tumors,  inflammatory  swellings,  and  reten- 
tion cysts. 

Inflammatory  hyperplasia  of  tissue  due  to  infection  by  micro-or- 
ganisms is  sometimes  mistaken  for  a  neoplasm,  and  vice  versa.  The 
difference  between  them,  however,  may  be  recognized  by  several  im- 
portant features  in  their  history.  In  inflammatory  swellings,  the 
growth  and  extension  are  often  very  rapid  and  progressive,  but  not 
continuous  nor  permanent.  There  is  lack  of  definite  outHne;  they  are 
amenable  to  agents  which  promote  absorption  by  neutralizing  or  re- 
moving the  primary  cause,  and  they  are  subject  to  early  and  acute 
degenerative  changes.  An  acute  suppurative  inflammation,  on  ac- 
count of  its  violent  local  and  general  symptoms,  is  rarely  mistaken  for 
a  malignant  neoplasm;  while,  on  the  other  hand,  new  growths  are 
usually  characterized  by  their  definite  outline,  slow  but  progressive 
growth,  permanency  of  the  new-formed  tissue,  and  their  resistance  to 
internal  medication. 

In  certain  forms  of  innocent  tumors,  like  neuroma  and  osteoma, 
growth  becomes  spontaneously  arrested  when  they  have  reached  a 
definite  size.  The  nearer  the  new  growth  resembles  normal  tissue,  the 
greater  the  probability  that  it  will  be  spontaneously  arrested  in  its 
growth.  Occasionally,  in  rapid-growing  malignant  neoplasms,  such 
inflammatory  symptoms  as  enlargement  of  the  superficial  veins  and 
edema  may  be  present.  Senn  emphasizes  the  fact  that  the  nearer  a 
malignant  tumor  resembles  an  inflammatory  swelling  the  greater  is  its 
malignancy. 

30  449 


450 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


Origin. — Xearly  all  new  growths  originate  from  misplaced  em- 
bryonic cells,  and  this  constitutes  the  matrix  from  which  the  tumor  is 
developed.  Cohnheim  was  of  the  opinion  that  all  tumors  were  of  con- 
genital origin,  and  were  developed  from  a  matrix  of  embryonic  tissue, 

Fig.  192. 


c  ^x> 


Manner  OF  Production  OF  Traumatic    Epithelial  Cyst,    f  After  Garr6.) 
a,  skin  ;  b,  subcutaneous  tissue;  c,  dislocated  fragment  of  skin. 

while  Garre,  Senn,  and  others  believe  they  may  be  occasionally  of  post- 
natal origin,  and  independent  of  causes  arising  from  the  action  of 
micro-organisms, — that  they  may  be  derived  from  pre-existing  mature 
cells,  which  in  consequence  of  injury  or  disease  fall  short  of  complete 

Fig.  193. 


Beginning  of  Healing  of  the  Skin-Defect  and  Commencing  Proliferation  from  the 
Margins  of  the  Implanted  Skin.     (After  Garre.) 

differentiation,  thus  forming  a  tumor-matrix,  from  which  a  neoplasm 
may  be  developed  in  the  same  manner  as  from  embryonic  cells  which 
have  been  misplaced  during  fetal  life.  Figs.  192,  193,  and  194  illus- 
trate the  origin  of  a  post-natal  epithelial  tumor. 


Fig.  194. 


-<t 


Wound  entirely  Healed,  and  the  Buried  Skin-Graft  enlarged  by  Proliferatio.n  from 
THE  Surface  and  Margins  of  the  Graft.    (After  Garrfi.) 


Cohnheim  was  the  first  to  teach  that  all  tumors  were  developed 
from  embryonic  tissue,  and  to  trace  their  origin  to  the  various  layers 
of  the  germinal  disk.     Ziegler,  however,  looks  upon  the  theory  of 


TUMORS.  451 

Cohnheim  as  more  or  less  hypothetical,  and  the  present  knowledge  of 
the  etiology  of  tumors  in  general  as  still  very  defective.  He  considers 
the  histologic  evidence  of  the  existence  of  embryonal  germinal  tissue  in 
the  fully  developed  organism  as  very  inadequate,  and  that  it  is  a  "bold 
step  to  ascribe  an  embryonic  origin  to  all  forms  of  tumors."  The 
two  latest  and  most  reliable  authorities  upon  the  subject  of  tumors— 
Sutton,  "Tumors,  Innocent  and  Benign,"  1893,  and  Senn,  "Pathology 
and  Surgical  Treatment  of  Tumors,"  1895— both  accept  the  teaching 
of  Cohnheim  in  relation  to  the  congenital  origin  of  nearly  all  forms  of 
neoplasms  and  their  development  from  misplaced  embryonic  tissue. 

Germinal  Layers.— Pander  discovered,  in  1847,  that  in  the  em- 
bryo of  the  chick  the  germinal  disk  was  composed  of  three  layers,— 
the  external  he  denominated  the  serosa;  the  internal,  the  mucosa;  and 
the  middle,  a  muscular  layer.  They  are  now  usually  designated  as  the 
external  layer  or  epiblast,  the  internal  or  hypoblast,  and  the  middle 
layer  or  mesoblast.  The  layers  can  be  plainly  distinguished  and  their 
complicated  arrangement  readily  traced  in  the  embryo  of  the  chick  on 
the  second  day  of  incubation.     (Fig.  195.) 


U       itur    ao     sf     ttd   elf 

Transverse  Section  through  Embryo  of  Chick  Two  Days  Old.    X  loo.     (After  Kolliker.) 

dd,  hypoblast;  cA,  cord  ;  tew,  primitive  vertebra  ;  unh,  primitive  vertebral  canal;  ao,  primitive 
aorta;  ung,  primitive  urinary  canal ;  sp,  cleft  in  lateral  plates  (first  indication  of  pleuro-peritoneal 
cavity),  which  though  lost  in  the  hp  and  intestinal  connective-tissue  plates  df,  are  connected  through 
the  mesoblast  ?«^  ,■  mr,  medullary  tube ;  A,  epiblast  thickened  at  some  points.  The  embryo  at  the 
time  is  composed  of  two  epithelial  layers,  the  outer  the  epiblast,  the  inner  the  hypoblast,  connected  by 
the  middle  layer,  the  mesoblast. 

Embryologists  trace  the  origin  of  all  the  tissues  and  organs  of  the 
vertebrate  animals,  including  the  human  species,  to  these  three  general 
layers,  which  may  be  distinguished  in  the  various  embryos  during  the 
first  few  days  after  conception.  From  the  epiblast  are  developed  all 
those  tissues  and  organs  of  epithelial  structure,  the  skin  and  its  glandu- 
lar appendages,  the  hair,  the  nails,  the  lens  of  the  eye,  the  brain  and 
spinal  cord,  the  epithelial  lining  of  the  mouth,  the  nasal  passages,  the 
labyrinth  of  the  ear,  and  the  teeth.  From  the  hypoblast  there  are  devel- 
oped the  mucous  membrane  of  the  entire  alimentary  tract,  with  all  its 
glandular  appendages,  the  urinary  organs,  the  liver,  the  lungs,  the  thy- 
roids, and  the  kidneys.  From  the  mesoblast  is  formed  the  great  bulk 
of  the  body,  viz:  The  bones,  the  connective  tissues,  the  muscles,  the 
nerves,  the  serous  membrane  and  its  glands,  the  vascular  organs,  the 
lymphatics,  the  ductless  glands,  the  thymus,  and  the  spleen. 


452  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

In  the  differentiation  of  the  cells  which  takes  place  in  the  embryo, 
each  cell  is  endowed  with  its  own  particular  genetic  function  of  form- 
ing other  cells  like  itself,  but  farther  than  this  it  cannot  go.  Cells  may 
be  arrested  in  their  growth,  and  their  character  thereby  somewhat 
changed,  but  there  is  never  a  transition  from  one  variety  to  another, 
and  this  law  remains  in  force  during  the  entire  life  of  the  organism. 

When  incomplete  differentiation  has  taken  place  in  some  mis- 
placed portion  of  one  of  these  germinal  layers,  it  often  remains  buried 
in  the  tissues  in  its  embryonic  state  for  an  indefinite  period,  but  it  may 
take  on  active  growth  at  any  time,  with  the  result  of  invariably  pro- 
ducing a  tumor  corresponding  in  its  structure  to  the  variety  and 
stage  of  development  of  the  cells  from  which  it  had  its  origin. 

Structure. — "A  tumor-matrix  of  congenital  origin  always  repre- 
sents normal  tissue-elements  in  an  abnormal  place."  (Senn.)  The 
histologic  structure  of  the  tissue  which  composes  a  new  growth  is 
governed  by  the  inherent  genetic  function  of  the  embryonic  cells  which 
form  the  tumor-matrix.  A  matrix  derived  from  the  epiblast  or  the 
hypoblast  would  invariably  produce  a  tumor  of  the  epithelial  type, 
while  if  derived  from  the  mesoblast  the  result  would  be  the  formation 
of  a  tumor  of  the  connective-tissue  type.  Senn  maintains  that  the 
character  of  the  neoplasm  "depends  upon  the  stage  of  arrested  cell- 
growth"  in  the  tumor-matrix.  The  nearer  the  tissue  composing  the 
tumor-matrix  approaches  the  completion  of  the  process  of  cell-differ- 
entiation, the  greater  the  probability  that  the  tumor  which  may  be 
developed  from  it  will  be  benign  in  character,  while,  upon  the  other 
hand,  the  nearer  it  resembles  embryonic  tissue — the  more  immature 
the  cells — the  greater  the  liability  that  the  tumor  will  be  of  a  malignant 
type. 

A  tumor-matrix  derived  from  the  epiblast  or  the  hypoblast,  and 
composed  of  cells  in  which  the  process  of  differentiation  has  been 
almost  completed,  would  give  rise  to  a  benign  tumor  of  the  epithelial 
type,  viz:  a  papilloma,  or  an  adenoma,  while  if  composed  of  cells  in 
which  this  process  was  arrested  in  its  earlier  stages,  it  would  result  in 
the  formation  of  a  malignant  tumor  of  the  same  type,  an  epithelioma 
or  a  carcinoma.  Senn  makes  no  distinction  in  malignant  tumors  of 
the  epithelial  type,  but  classes  them  all  as  carcinomata. 

In  tumors  arising  from  the  mesoblastic  layer,  the  same  conditions 
are  manifest;  a  tumor-matrix  composed  of  connective-tissue  cells  of 
high  differentiation  will  produce  an  innocent  tumor  of  the  connective- 
tissue  type,  viz:  A  fibroma,  chondroma,  or  an  osteoma,  while  if  of  low 
differentiation  it  will  be  likely  to  result  in  the  development  of  a 
sarcoma. 

The  structure  of  benign  tumors  so  closely  resembles  normal  tis- 
sue, both  macroscopically  and  microscopically,  that  it  is  many  times 


TUMORS.  453 

exceedingly  difficult  to  distinguish  between  them.  The  same  is  true 
of  their  cellular  elements.  The  cells  retain  the  original  form  and  type 
of  the  tissues  from  which  they  had  their  origin,  and  as  they  reach  their 
highest  degree  of  development  it  becomes  almost  impossible  to  dififer- 
entiate  between  the  tumor-cells  and  the  normal  cells  representing  the 
tissue  from  which  they  originated. 

The  structure  of  malignant  tumors  is  distinguished  by  the  embry- 
onic or  immature  character  of  the  tumor-cells,  which  closely  resemble 
the  fixed-tissue  cells  in  their  early  stage  of  development.  "The  strik- 
ing difiference  between  a  sarcoma  cell  and  an  immature  connective- 
tissue  cell  is  in  the  size  and  number  of  their  nuclei."  (Senn.)  In  the 
sarcoma  cells  the  nucleus  is  large  and  often  multiple,  w^hile  in  the 
connective-tissue  cells  it  is  single  and  much  smaller  in  comparison 
with  the  nucleus  of  the  sarcoma  cells.  Another  distinguishing  feature 
of  the  sarcoma  cells  is  their  lack  of  uniformity  in  size,  form,  and  color. 
The  chief  varieties  of  the  sarcoma  cells  are  the  round,  fusiform,  mye- 
loid, and  pigmented. 

In  malig'nant  tumors  of  the  epiblast  and  hypoblast  the  cells  are 
characterized  by  their  immature  or  embryonic  development,  and  they 
bear  a  very  close  resemblance  to  the  cellular  elements  which  are 
found  in  these  layers  of  the  germinal  disk.  Here,  also,  the  cells  lack 
uniformity  in  size  and  shape.  They  vary  in  size  from  1-600  to  1-1500 
of  an  inch  in  diameter,  and  are  polygonal,  round,  oval,  caudate,  and 
fusiform  in  shape,  while  the  nuclei  of  the  epithelioma  and  carcinoma 
cells,  as  in  the  sarcoma  cells,  are  multiple.  At  one  time  the  poly- 
morphic character  of  the  cells  in  epithelial  tumors  was  supposed  to  be 
diagnostic  of  carcinoma,  but  it  is  now  thought  to  be  the  result  of  rapid 
cell-proliferation  and  pressure.  Nevertheless,  the  polymorphic  charac- 
ter of  the  cells  and  the  large  multiple  nuclei,  though  they  cannot  be 
considered  as  positively  diagnostic  of  a  malignant  growth,  yet  they  cast 
suspicion  of  malignancy  upon  all  neoplasms  in  which  they  are  found. 

Growth. — Tumor-cells  multiply,  like  their  prototypes,  the  normal 
cells,  by  a  process  of  indirect  division,  or  segmentation,  known  as 
karyokinesis.  Nearly  all  the  fixed-tissue  cells  of  the  higher  type  mul- 
tiply in  this  manner.  Growth  in  benign  tumors  is,  as  a  rule,  much 
slower  than  in  the  malignant  form.  A  fibroma  may  require  years  to 
attain  the  size  of  a  man's  fist,  but  a  malignant  growth  may  reach  the 
same  dimensions  in  a  few^  months.  Cell-proliferation  is  very  active  in 
the  malignant  tumors,  which  results  in  rapid  growth  and  defective 
development  of  the  cellular  elements.  The  kinetic  process,  as  de- 
scribed by  Strassburger,  consists  of  three  stages.  During  the  first 
stage,  or  Prophase,  the  nuclear  chromatin  arranges  itself  in  the  form  of 
an  oval  mass.  In  the  second  stage,  or  Mctaphase,  the  nucleus  elon- 
gates or  becomes  barrel-form,  wdth  a  suggestion  of  equatorial  division. 


454  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

During  the  last  stage,  or  Anaphase,  the  nucleus  and  protoplasm  are 
divided  into  two  symmetrical  halves,  and  separate,  thus  completing 
the  process  of  segmentation.  (See  Figs.  55,  56,  57,  58.)  Segmenta- 
tion of  the  nucleus  without  division  of  the  protoplasm  results  in  the 
formation  of  multinuclear  and  giant  cells.  Such  imperfect  karyo- 
kinesis  is  frequently  found  in  the  cellular  elements  of  malignant  neo- 
plasms. In  the  study  of  the  kinetic  process  in  malignant  tumors, 
pathologists  have  discovered  that  the  same  phases  are  passed  through 
as  in  the  formation  of  normal  tissues,  with  the  exception  that  com- 
plete cell-dififerentiation  is  seldom  reached  in  this  form  of  tumor. 

Character. — Clinically  all  neoplasms  are  divided  into  three 
classes,  viz:  Benign,  malignant,  and  suspicious.  The  class  to  which 
each  belongs  is  determined  by  the  character  of  the  tissue  which  com- 
poses them,  and  the  stage  of  development  of  the  cellular  elements. 
The  more  nearly  a  tumor  approaches  to  normal  tissue  of  the  class 
from  which  it  originated,  the  greater  are  the  chances  that  it  will  prove 
benign;  while,  on  the  other  hand,  the  more  nearly  the  tissue  and  cells 
simulate  an  embrj'onic  development,  the  greater  is  the  liability  that  the 
tumor  will  be  malignant.  The  suspicious  tumors  are  those  which  do 
not  belong  strictly  to  the  benign  or  malignant  forms,  but  contain 
elements  of  both — the  mixed  tumors^ — or  which  are  liable  to  take  on 
active  cell-proliferation  of  an  embryonic  character  later  in  life,  as  the 
result  of  irritation. 

Certain  forms  of  tumors  may  remain  benign  in  character  for  years, 
when  suddenl}^  they  take  on  active  growth  or  cell-proliferation,  and 
assume  a  malignant  type.  This  is  particularly  true  of  papilloma  and 
adenoma.  Senn  believes  that  this  sudden  change  in  the  clinical  be- 
havior of  tumors  is  not  an  evidence  of  the  semi-malignant  nature  of  the 
growth,  but  that  it  was  either  malignant  from  its  incipiency,  or  that 
it  has  undergone  changes  which  give  it  a  malignant  character. 

The  most  marked  clinical  features  which  distinguish  the  benign 
from  the  malignant  tumors  are:  First,  a  benign  tumor  never  extends 
to  other  tissue  than  that  from  which  it  had  its  origin,  while  all  malig- 
nant tumors  extend  to  and  involve  other  tissues  than  those  from 
which  its  matrix  was  derived.  For  instance,  a  benign  epithelial 
growth  is  always  confined  to  the  epithelial  structures  of  the  epiblast 
or  the  hypoblast,  while  a  malignant  epithelial  tumor  would  involve  the 
tissues  in  its  neighborhood  irrespective  of  their  character  or  origin. 
Second,  a  malignant  epithelial  tumor  has  a  tendency,  which  is  made 
manifest  early  in  its  history,  to  involve  the  lymphatic  glands,  begin- 
ning with  those  most  closely  associated  with  the  particular  location 
of  the  tumor,  and  extending  through  the  lymph-channels  to  others 
farther  removed.  These  two  features  have  been  regarded  for  a  long 
time  as  the  most  reliable  clinical  evidence  of  the  malignant  character 


TUMORS.  455 

of  those  tumors.  The  manifestation  of  these  evidences,  however,  par- 
ticularly the  latter,  comes  too  late  to  prove  of  value  from  the  stand- 
point of  effecting  a  radical  cure.  When  extension  to  and  involvement 
of  surrounding  tissues  has  become  very  marked,  or  the  lymphatics 
are  implicated,  there  is  little  hope  of  a  radical  cure  of  the  disease. 

The  character  of  the  tumor  can  be  diagnosed  in  most  cases  by  the 
microscope,  and  yet,  as  we  have  already  seen,  there  are  certain  malig- 
nant tumors  which  have  a  cellular  structure  in  their  early  stages,  so 
closely  resembling  the  embryonic  cells  of  the  various  germinal  layers 
from  which  they  spring,  that  it  is  difficult  to  distinguish  between  them. 
Consequently,  every  tumor  which  cannot  be  satisfactorily  diagnosed 
to  be  a  benign  growth  should  be  classed  as  malignant,  and  immedi- 
ately extirpated  as  the  only  safe  method  of  dealing  with  it.  Waiting 
for  positive  evidence  of  malignant  character  before  recommending  a 
radical  operation  is  foolhardy  in  the  extreme,  for  when  positive  evi- 
dence is  at  hand,  it  may  be  too  late  to  avert  a  fatal  termination  of  the 
disease. 

Classification. — Tumors  are  now  usually  classified  from  two 
standpoints:  First,  from  their  origin  and  histologic  structure,  and 
second,  from  the  stage  of  development  of  the  cells  composing  the 
tumor-matrix.  The  germinal  layers  from  which  the  neoplasms  have 
their  origin  indicate  the  type  of  the  growth,  while  the  stage  of  arrested 
development  of  the  cellular  elements  of  the  matrix  will  indicate  the 
character  of  the  tumor.  Tumors  of  highly  organized  tissue  represent 
the  benign  growths.  Those  approaching  embryonic  conditions  of 
tissue  represent  the  malignant  growths.  The  first  systematic  classifi- 
cation of  tumors  was  that  made  by  Virchow,  in  which  he  made  the 
attempt  to  arrange  all  tumors  according  to  their  histologic  structure. 

Virchow' s  Classification  of  Tumors. 

1.  Histioid; 

2.  Organoid; 

3.  Granulomata  ; 

4.  Teratoid; 

5.  Combination  tumors; 

6.  Extravasation  and  exudation  tumors. 

7.  Retention  cysts. 

This  classification,  in  view  of  our  present  knowledge  of  the  origin 
and  cause  of  certain  tumors,  seems  very  imperfect  indeed. 

All  tumors  composed  of  one  kind  of  cells  Virchow  classed  as 
"histioid  tumors."  Klebs  maintains  that  a  pure  histioid  tumor  is  only 
found  in  very  small  epitheliomas,  sarcomas,  and  in  angeiomas.  As 
"organoid  tumors"  he  classed  all  those  growths  which  are  composed 
of  several  kinds  of  cells  arranged  in  definite  and  typical  forms,  repre- 


4S6  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

senting  the  structure  of  organs.  Senn  thinks  this  term  is  incorrect 
and  misleading,  for  the  reason  that  even  the  most  perfectly  developed 
adenoma,  or  any  other  form  of  tumor,  for  that  matter,  is  devoid  of 
physiologic  function.  Among  the  "granulomata"  which  are  infec- 
tive inflammatory  swellings,  he  includes  carcinomata  and  sarcomata, 
but  until  it  can  be  proved  that  these  tumors  are  the  result  of  microbic 
infection,  they  have  no  place  with  the  granulomata.  The  "teratoid" 
tumors  include  all  those  growths  which  are  composed  of  a  system  of 
organs,  like  dermoid  cysts,  an  extra  digit  or  limb,  or  a  fetus  within  a 
fetus.  "Combination  tumors"  are  those  which  are  composed  of  two 
or  more  kinds  of  tumor  tissues.  The  "extravasation  and  exudation 
tumors"  are  the  result  of  traumatism  or  inflammation,  and  should  be 
classed  with  the  granulomata  and  inflammatory  swellings.  "Reten- 
tion cysts"  should  also  be  classed  by  themselves,  as  they  are  in  no 
sense  neoplasms. 

Virchow  also  divided  tumors  into  two  general  groups.  One  he 
denominated  Homologous,  and  the  other  Heterologous.  In  the  first 
group  he  included  all  tumors  whose  histologic  structure  closely  re- 
sembles normal  tissue,  and  reproduces  the  type  of  tissue  of  the  organ 
or  part  in  which  they  are  located.  In  the  second  group  he  placed 
all  growths  which  deviate  in  their  histologic  structure  from  the  type 
of  tissue  from  which  the  tumor  had  its  origin.  From  the  clinical 
standpoint  all  homologous  tumors  may  be  said  to  be  benign,  and,  in 
a  general  way,  all  heterologous  tumors  may  be  classed  as  malignant. 
There  are  exceptions,  however,  to  this  rule.  A  chondroma  is  a  heter- 
ologous tumor,  but  it  is  benign;  while  on  the  other  hand  malignant 
tumors  sometimes,  in  their  early  stages,  present  a  homologous  struc- 
ture. Malignant  tumors,  however,  are  always  heterologous  in  their 
structure. 

Cohnheim,  as  already  stated,  was  the  first  to  classify  tumors  ac- 
cording to  their  embryonic  origin.  The  classification  is,  however, 
somewhat  imperfect,  as  the  myomata  and  neuromata  should  be  classed 
with  the  tumors  of  the  connective-tissue  type. 

'  Cohnheim' s  Classification  of  Tumors. 

'  Fibroma  (Fibrous-tissue  tumor). 
Lipoma  (Fatty  tumor). 
Myxoma  (Mucoid  tumor). 
I.  Chondroma  (Cartilaginous  tumor). 

Connective-tissue   ^   Osteoma  (Bony  tumor). 

Type.  i   Angioma  (Vascular  tumor). 

Lymphangioma  (Lymphatic-vessel  tumor). 
I    Lymphoma  (Lymphatic-gland  tumor), 
t.  Sarcoma  (Embryonic  connective-tissue  tumor). 


TUMORS. 


457 


11. 

Epithelial  Type. 


III.     I 

Myomata.  ^ 


IV. 
Neuromata. 


f  Epithelioma  (Epithelial  tumor  of  skin  or  mu- 
cous membrane). 

Onychoma  (Horny  tumor). 

Struma  (Scrofulous  tumor). 

Cystoma  (Cystic  tumor). 

Adenoma  (Glandular  tumor). 
,  Carcinoma  (Embryonic  epithelial-tissue  tumor). 

f     Myoma      laevi-cellulare      (Involuntary-muscle 
tumor). 
]\Iyoma   strio-cellulare    (Voluntary-muscle   tu- 
mor). 
Neuroma  (Nerve-tissue  tumor). 
Glioma  (Klebs).     (Connective-tissue  tumor  of 
nerve  and  brain.) 

V.  f  Teratoma  (Virchow).       (Tumors  composed  of 

Teratomata.  (  various  tissues  or  organs.     Monstrosities.) 

Sutton,  in  his  classification  of  tumors,  makes  the  attempt  to  bring 
order  out  of  confusion  by  following  lines  of  classification  similar  to 
those  employed  in  biology,  and  divides  tumors  into  four  groups,  viz: 
First,  connective-tissue  tumors;  second,  epithelial  tumors;  third,  der- 
moids; fourth,  cysts.  These  he  again  subdivides  into  genera,  species, 
and  varieties,  according  to  their  histologic  structure  and  character. 

This  classification  is  a  great  improvement  over  those  of  Virchow 
or  Cohnheim,  by  reason  of  the  fact  that  it  is  based  upon  the  origin  and 
the  character  of  the  histologic  structures  which  compose  the  tumors. 

Sutton's  Classification  of  Tumors. 

Lipomata. 
Chondromata. 
Osteomata. 

Odontomata  (tooth  tumors). 
Fibromata. 
I.     Group,        ;     Myxomata. 
Connective  Tissue.    \     Gliomata  (neuroglia  tumors). 
i     Sarcomata. 

Myomata  (muscle  tumors). 
Neuromata  (tumors  on  nerves). 
Angiomata. 
Lymphangiomata. 


458 


SURGERY   OF   THE    FACE,    MOUTH,    AND   JAWS. 


Papillomata 


II.     Group, 
Epithelial  Tissue. 


III.     Group, 
Dermoids. 


j  Skin  warts. 
I  Villous  papillomata. 
j  Intra-cystic  warts, 
t  Psammomata  (Meningeal  tumors). 
Epithelioma   (Epithelioma). 

Mammary.  Renal. 

Sebaceous.  Ovarian. 

Thyroid.  Testicular. 

Adenoma       ■{  Pituitary.  Gastric. 

Prostatic.  Intestinal. 

Parotid.  Fallopian. 

i  Hepatic.  Uterine. 

i\Iammary.  Renal. 

Sebaceous.  Ovarian. 

Carcinoma        Thyroid.  Testicular, 

(cancer)    ."^  Prostatic.  Gastric. 

Parotid.  Intestinal. 

Pancreatic.  Fallopian. 

Hepatic.  Uterine. 

Sequestration   dermoids;   Tumors   from   hidden 

surface  epithelium. 
Tubulo-dermoids;   Tumors   from   obsolete   fetal 

canals. 
Ovarian  dermoids. 
Dermoid  patches. 

f  Retention  cysts. 


IV.     Group, 
Cysts. 


Tubulo-cysts. 


Hydroceles. 
Gland  cysts. 

f  Diverticula. 
Sub-group,  I   Bursse. 

Pseudo-cysts.      |   Neural  cysts. 
(^  Parasites. 
Senn  classifies  tumors  with  special  reference  to  their  relationship 
to  the  various  germinal  layers,  and  the  stage  of  arrested  cell-develop- 
ment in  the  elements  composing  the  tumor-matrix. 

Senn's  Classification  of  Tumors. 
f   Papilloma. 
I,  Epiblastic  and  Hy-    j    Adenoma. 
poblastic  Tumors.      i    Cystoma. 
I    Carcinoma. 


TUMORS. 


459 


Fibroma. 

Lipoma. 

Myxoma. 

Chondroma. 

Osteoma. 

Angioma. 

TT    ■»  r      ,  ,      •    rj.  j  Lymphangioma. 

IL  Mesoblastic  Tumors.  1  ^       ^,      ^ 

Lymphoma. 

Myomata 
Neuromata 


^  Sarcoma. 


(Laevi-cellulare ; 
Strio-cellulare). 
(Neuroma;  MyeHnic; 

Amyelinic). 
Glioma  (Klebs). 


IIL     Epiblastic,   Hy-  ] 
poblastic,      and 
Mesoblastic  Tu- 


)-     Teratomata. 


mors. 


IV.  Swellings  caused  | 


by    retention    of   i  ^ 

,      .  ,      .  (  Retention  cysts, 

physiologic     se-    | 

cretions.  j 


CHAPTER    XLVI. 


TUMORS  OF  THE  FACE,  MOUTH,  AND  JAWS. 

Epithelial  Tumors. 

The  various  forms  of  tumors  which  are  most  commonly  found 
associated  with  the  face,  mouth,  and  jaws  are : 


Epithelial  Group, 

or 
Epiblastic  and 
Hypoblastic  Tumors. 

Connective-Tissue  Group, 
or 
Mesohlastic  Tumors. 

Composite  Group, 

or 
Epiblastic,  Hypoblastic, 
and  Mesoblastic  Tumors. 

Swellings  resulting  from 
retention  of  normal 
secretions. 


Papillomata. 
Adenomata. 
Cystomata. 
Carcinomata. 

Fibromata. 

Chondromata. 

Osteomata. 

Angiomata. 

Sarcomata. 


Odontomata. 


1 

)■  Retention  Cysts. 


J 


In  the  consideration  of  the  subject  of  tumors  located  in  the  region 
of  the  face,  the  foregoing  order  will  be  followed,  for  the  reason  that 
the  student,  it  is  hoped,  will  gain  a  better  knowledge  of  the  character 
and  tendencies  of  such  growths  if  they  are  studied  in  separate  groups, 
and  according  to  their  classification,  from  the  standpoint  of  their  histo- 
genesis and  morphology. 

The  Epithelial  group  comprises  all  of  those  neoplasms  which  have 
their  origin  in  the  epiblast  or  hypoblast.  In  these  tumors  the  epithelial 
elements  predominate;  in  fact,  they  constitute  the  essential  and  distin- 
guishing morphologic  forms.  The  functions  of  the  epithelium  are 
exceedingly  varied  in  man  and  in  animals  of  complex  organization; 
in  certain  locations  it  acts  as  a  protection;  as,  for  instance,  the  epi- 
dermis; it  also  becomes  modified  into  hair,  nail,  horn,  or  enamel;  in 
460 


TUMORS    OF   THE    FACE,    MOUTH,    AND    JAWS.  461 

Others  the  epithehal  cells  extend  into  the  connective  tissue  beneath,  in 
the  form  of  processes,  to  form  secreting  glands,  some  of  which  are 
simple;  as,  for  instance,  the  tubular  glands  of  the  intestines;  others 
are  complex,  such  as  the  liver,  kidneys,  pancreas,  mammae,  and  the  sali- 
vary glands.  But  whether  the  gland  is  simple  or  complex,  the  under- 
lying principle  of  construction  is  the  same  (Sutton),  and  is  character- 
ized by  narrow  canals  lined  with  epithelial  cells  arranged  in  a  definite 
order,  the  canals  resting  upon  a  connective-tissue  groundwork,  which 
is  ramified  with  blood-vessels,  lymphatics,  and  nerves.  The  canals,  or 
"epithelial  recesses,"  of  a  gland  are  known  as  acini.  Each  acinus 
either  directly  communicates  with  a  free  surface  of  the  body  by  means 
of  its  own  duct,  as  in  the  simple  mucous  and  sebaceous  glands;  or 
through  several  main  ducts,  as  in  the  complex  structure  of  the  mam- 
mas; or  by  a  common  duct,  as  in  the  equally  complex  structures  of  the 
parotid  gland  and  the  pancreas.  Sutton  calls  attention  to  three  notable 
exceptions  to  this  rule,  viz:  the  thyroid  glands,  the  pituitary  bodies, 
and  the  ovaries.  All  other  secreting  glands  possess  means  of  direct 
communication  with  free  surfaces  of  the  body,  and  are  therefore  subject 
to  infection  from  all  forms  of  micro-organisms. 

All  epithelial  tumors  are  composed  of  two  kinds  of  tissue, — epi- 
thelial cells  and  vascular  connective  tissue,  the  latter  forming  the 
stroma  or  framework  in  which  the  epithelial  cells  are  imbedded  (Zieg- 
ler) ;  while  the  number,  character,  and  arrangement  of  the  cells  indicate 
the  variety  of  tumor  and  its  benign  or  malignant  tendencies.  The 
general  plan  of  construction  of  epithelial  tumors  is  that  of  a  simple 
gland,  and  this  form  is  maintained  throughout  many  phases  of  their 
development.  The  degree  of  resemblance,  however,  differs  greatly 
in  the  various  forms.  The  adenomata  most  nearly  resemble  the  struc- 
ture of  some  particular  glandular  type.  The  tumors  which  are  farthest 
removed  from  this  regularity  in  structure  are  the  epitheliomata  and  the 
carcinomata.  In  these  the  epithelial  cells  are  arranged  in  "compact, 
irregular  masses," — "cell  nests," — while  in  the  adenomata  the  tendency 
is  to  a  regular  arrangement,  the  cells  lining  the  inner  wall  of  the  alveoli 
and  leaving  an  open  space  or  lumen  which  corresponds  to  the  saccule 
or  acinus  of  a  gland.  It  has  already  been  intimated,  in  the  preceding 
chapter,  that  tumors  which  in  their  structure  closely  resemble  the  nor- 
mal tissues  of  the  part  in  which  they  are  located  are  benign,  and  that 
tumors  of  an  opposite  character  are  malignant,  or,  to  state  it  more 
correctly,  the  nearer  the  cells  v\^hich  give  special  character  to  the  tumor 
approach  complete  differentiation  the  more  certain  are  they  to  be 
innocent;  while,  on  the  other  hand,  the  more  nearly  these  cells  ap- 
proach an  embryonic  condition  of  development  the  greater  the  cer- 
tainty that  they  are  malignant. 

Epithelial  tumors  are  developed  by  a  multiplication  of  the  epi- 


462  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

thelial  cells.  These  are  imbedded  in  the  connective  tissue,  which  is 
also  undergoing  multiplication  of  its  cellular  elements.  This  multi- 
plication of  cells  may  be,  in  certain  forms  of  tumors,  in  the  line,  ap- 
parently, of  a  normal  development  of  tissue,  but  in  abnormal  numbers, 
as  when  located  in  the  papillary  layer  of  the  skin  or  mucous  membrane, 
and  resulting  in  the  formation  of  papillomata;  or  the  new  formation 
may  exhibit  a  structure  resembling  that  of  glandular  tissue,  and  result 
in  the  formation  of  adenomata;  in  others  the  structural  arrangement 
may  very  imperfectly  represent  glandular  tissue,  exhibiting  only  the 
earliest  stages  of  gland  formation;  or  the  epithelial  cells  may  be 
gathered  into  "irregular,  compact  masses,"  with  a  tendency  to  unlim- 
ited growth,  as  in  carcinoma. 

In  the  epithelial  type  of  tumor,  especially  in  carcinoma,  the  epi- 
thelial cells  lie  in  close  contact  with  one  another,  and  are  seemingly 
united  by  a  cement  substance,  or  are  continuous  with  one  another 
(Warren).  These  "cell  nests"  are  not  directly  supplied  with  blood- 
vessels. The  connective-tissue  framework  or  stroma,  which  is  ar- 
ranged in  the  form  of  alveoli,  contains  the  blood-vessels.  The  epi- 
thelial cells  lie  within  the  alveoli,  and  are  sometimes  so  arranged  as  to 
give  the  appearance  of  a  "bird's  nest."  The  absence  of  tissue  between 
the  cells  is  characteristic  of  epithelial  tumors  (Warren),  and  forms 
a  diagnostic  sign  by  which  doubtful  cases  of  carcinoma  may  be  differ- 
entiated from  alveolar  sarcoma.  In  alveolar  sarcoma  the  cells  resemble 
those  of  carcinoma,  but  a  close  inspection  reveals  the  fact  that  they 
are  separated  by  a  delicate  connective-tissue  framework  or  reticulum. 

Papillomata. 

Definition. — Papilloma  (Lat.  Papilla^  a  nipple;  Gr.  op.'i^  ending  in- 
dicating a  swelling  or    a  tumor). 

A  term  employed  to  include  corns,  warts,  horns,  and  certain  nevi. 
A  papilloma  is  a  growth  on  the  skin  or  mucous  membrane,  based  upon 
or  resembling  a  normal  papilla. 

The  papillomata  are  epithelial  growths  occurring  upon  the  cuta- 
neous or  mucous  surfaces  of  the  body,  and  are  benign  in  character. 
These  formations  are  generally  considered  as  occupying  a  position 
midway  between  inflammatory  swellings  and  true  tumors,  though 
some  authors  class  them  among  the  fibromata. 

jMorphologically,  the  papillomata  belong  to  the  class  of  tumors 
which  arise  from  the  epiblast  and  hypoblast, — the  epithelial  group. 
They  are  essentially  composed  of  epithelial  cells,  but  the  framework 
or  stroma  is  furnished  by  the  underlying  connective  tissue,  conse- 
quently they  contain  elements  which  are  derived  from  the  mesoblast. 
All  epithehal  tumors  contain  more  or  less  connective  tissue  as  stroma. 
and,  strictly  speaking,  are  therefore  mixed  tumors,  though  they  are  not 


TUMORS    OF    THE    FACE,    MOUTH,    AND    JAWS.  4O3 

generally  classed  as  such.  The  new  tissue  developed  from  the  germinal 
layers  in  combination  is  never  uniform  in  quantity;  one  or  the  other 
element  predominates,  thus  giving  different  histologic  characters  to 
the  neoplasms.  This  has  made  it  somewhat  difificult  to  determine  to 
which  group  they  belong,  and  has  therefore  caused  the  confusion  in 
the  classification. 

Papillary  formations  are  frequently  found  in  tumors  which  do  not 
belong  to  this  class  of  new  growths;  hence  Virchow,  Rokitansky,  and 
others  have  objected  to  classifying  the  papillomata  as  a  distinct  type  of 
tumor,  Mrchow  named  them  "fihroma  papillare."  A\'arren  places 
them  among  the  epithelial  neoplasms.  Sutton  and  Senn  both  class 
them  as  epiblastic  and  hypoblastic  tumors. 

In  a  majority  of  those  tumors  which  can  be  classed,  morpho- 
logically, as  papillomata,  the  epithelial  elements  predominate  and  give 
character  to  the  growth;  while  in  others  in  which  the  fibrous  elements 
are  in  excess  this  circumstance  may  be  considered  as  an  accidental 
feature,  due  to  the  close  relationship  existing  between  the  epithelial 
structures  and  the  underlying  connective  tissue. 

In  papilloma  the  essential  part  of  the  tumor  is  composed  of  epi- 
thelial cells,  while  the  stroma  or  fibrous  element  is  derived  from  the 
connectiA'e  tissue,  and  contains  the  vascular  supply.  (Fig.  196.)  The 
type  of  papilloma  found  upon  the  skin  and  in  connection  with  the  mu- 
cous membrane  of  the  mouth,  tongue,  palate,  etc.,  consists  of  a  papilla, 
with  a  vascular  connective-tissue  base,  covered  with  epithelial  cells. 
They  may  be  defined  as  excrescences  from  the  epithelium  of  the  skin 
and  mucous  surfaces.  Their  blood-supply  varies  greatly,  but  in  cer- 
tain forms  associated  with  the  mucous  membrane  it  is  often  very  con- 
siderable. Usually  the  epithelium  covers  a  single  papilla  or  villus,  but 
occasionally  it  extends  over  several,  forming  smooth  plaques. 

The  papillomata  appear  in  two  forms, — the  hard  and  the  soft. 
The  hard  form  is  the  variety  commonly  located  upon  the  skin  and 
mucous  membrane,  and  generally  designated  by  the  term  Verruca  (an 
excrescence)  or  warts.  The  soft  form  is  most  frequently  associated 
with  the  mucous  membrane  of  the  bladder,  stomach,  duodenum,  and 
colon  (Birch-Hirschfeld),  and  also  of  the  uterus  (Warren).  Growths 
of  this  character  are  sometimes  found  springing  from  the  meninges 
of  the  brain,  and  may  grow  into  the  venous  sinuses  (Klebs). 

Sutton  divides  the  papillomata  into  four  species:  warts,  villous 
papillomata,  intracystic  warts,  and  psammomata.  The  difference  in 
this  classification  from  that  generally  followed  is  that  of  adding  intra- 
cystic warts  or  papillomata,  a  rare  variety  sometimes  found  in  mam- 
mary cysts,  and  of  making  separate  species  of  those  soft  villous  papil- 
lomata found  in  connection  with  the  pelvis  of  the  kidneys  and  the 
bladder,  and  of  the  epithelial  bodies  found  in  the  membranes  of  the 
brain  and  the  spinal  cord,  the  psammomata. 


464 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


Senn  classes  warts  with  the  condylomata  and  molluscuni  con- 
tagiosum,  which  are  inflammatory  swelHngs  of  infective  origin. 

Hard  papillomata  of  the  skin,  or  skin  warts,  are  the  most  common 
variety,  and  they  are  simply  overgrown  or  hypertrophied  papillae. 
They  may  occur  singly  or  in  groups,  and  unless  irritated  are  rarely 
painful.  The  most  common  locations  are  the  hands,  feet,  face,  scalp, 
neck,  and  genitals.  (Hyde.)  They  may  be  congenital  or  acquired. 
They  are  exceedingly  erratic  in  their  development  and  disappearance, 
their  growth  being  sometimes  slow,  sometimes  rapid;  they  may  persist 


Fig.  I 


Fibrous  tissue.^<i 


Papilloma  of  the  Skin  (Wart).    Transverse  Section.    X  60. 


for  years,  or  disappear  suddenly,  without  apparent  cause.  In  form 
they  may  be  sessile  or  pedunculated,  flat  or  pointed,  smooth  or  covered 
with  secondary  processes  presenting  a  mulberry-  or  cauliflower-like 
appearance.  In  color  they  may  be  like  the  skin  or  pigmented;  in 
some  cases  mottled  with  black.  In  size  they  may  vary  from  a  pin-head 
to  a  walnut,  or  even  attain  the  size  of  the  closed  fist.  They  some- 
times bleed  and  ulcerate  when  irritated,  and  occasionally  give  off  a 
very  offensive  odor. 

McCarthy  reported  a  case  (Sutton)  of  a  man  seventy-six  years 
old  having  a  tumor  which  sprang  from  the  cheek  and  attained  the  size 
of  half  an  orange,  and  completely  covered  the  right  eye.  (Fig.  I97-) 
Sutton  reports  a  similar  case  of  a  woman  forty  years  of  age,  with  the 


TUMORS    OF   THE    FACE,    MOUTH,    AND    JAWS. 


465 


tumor  growing  from  the  skin  of  the  left  temple,  and  another  of  a  man 
thirty-six  years  of  age,  in  whom  the  tumor  was  situated  in  the  center  of 
the  pubic  arch.  This  was  as  large  as  the  closed  fist,  of  the  color  of  a 
cock's  comb,  and  emitted  an  abominable  odor.  The  inguinal  glands 
were  enlarged  upon  both  sides,  but  after  the  removal  of  the  tumor  the 
enlargement  disappeared. 

Senn  thinks  papillomata  of  such  size  are  never  individual  growths, 
but  that  they  are  produced  by  a  confluence  of  several  tumors. 

Fig.  197. 


Papilloma — Wart — Growing  from  the  Skin  of  the  Cheek  and  Obscuring  the  Eye. 

(McCarthy,  after  Sutton.) 

The  hard  form  of  papilloma  is  also  found  in  connection  with  the 
mucous  membrane  of  the  lips,  cheeks,  tongue,  hard  and  soft  palates, 
uvula,  pharynx,  larynx,  and  nasal  cavity,  and  also  of  the  urethra,  labia, 
vagina,  cervix  uteri,  and  bladder. 

Papilloma  of  the  mucous  membrane  of  the  mouth  bears  a  close 
resemblance  to  the  ordinary-  seed  wart,  and  is  of  more  frequent  occur- 
rence than  is  commonly  supposed;  at  least  this  is  the  observation  of 
the  writer,  who  has  had  a  large  field  for  clinical  observation  of  the 
diseases  of  the  mouth,  and  has  found  many  opportunities  for  removing 
such  growths.     The  most  common  locations  are  the  lower  lip,  the  soft 

31 


466  SURGERY    OF   THE    FACE,    MOUTH,   AND   JAWS. 

palate,  and  tongue,  and  they  appear  in  both  the  sessile  and  pedun- 
culated forms.  Papillomata  of  the  larynx  are  the  most  common  of 
all  the  tumors  of  this  region,  comprising  about  75  per  cent.  (Bos- 
worth.)  Butlin  says  they  "are  among  the  more  common  of  the  inno- 
cent tumors  which  affect  the  tongue." 

Another  form  of  papilloma  is  occasionally  observed  upon  the 
gums,  the  hard  palate,  and  the  tongue,  in  which  the  papillae  are  greatly 
elongated,  and  the  base  of  the  tumor  is  of  a  dirty-white  hue.  Sir 
William  Fergusson  first  described  the  disease  in  the  London  Lancet^ 
September  6,  1862,  the  case  occurring  in  the  lower  jaw  of  a  man  of 
eighty  years. 

Salter  describes  the  same  case,  and  says  the  tumor  was  "a.  curious 
white  mass,  consisting  of  coarse  detached  fibers;  in  fact,  it  was  a  mass 
of  papillae,  many  of  them  an  inch  long,  and  similar  in  shape  to  the  fili- 
form papillae  of  the  tongue;  their  surface  was  shreddy  and  broken; 
among  these  elongated  processes  were  a  few  rounded  eminences  like 
fungiform  papillae,  and  these  had  a  smooth,  unbroken  surface."  A 
similar  case  occurring  in  the  hospital  practice  of  Mr.  Cock,  of  Guy's 
Hospital,  and  reported  by  Salter,  was  located  upon  the  right  side  of 
the  hard  palate,  and  of  the  size  of  a  "split  chestnut;"  had  been  growing 
about  eight  months.  Tumors  of  this  character  seem  to  possess  a 
tendency  toward  malignancy. 

Papillomata  of  the  tongue  are  of  frequent  occurrence.  They  are 
usually  located  upon  the  dorsum  of  that  organ,  and  are,  in  all  prob- 
ability, caused  by  hypertrophy  of  natural  papillae.  They  are  not  lim- 
ited, however,  to  the  papillary  area,  but  may  have  their  seat  upon  the 
under  side  of  the  tongue,  where  the  surface  is  quite  smooth.  (Butlin.) 
They  appear  as  "small  white  tufts,"  usually  upon  a  sessile  base. 

Papillomata  may  appear  at  any  time  of  life.  Butlin  mentions 
a  case  occurring  in  an  infant  ten  months  old.  The  disease  occurs  most 
frequently,  however,  in  the  later  years  of  life,  between  sixty  and  seventy 
years  of  age  (Watson),  and  oftener  in  men  than  in  women. 

Diagnosis. — The  diagnosis  of  papilloma  of  the  skin  is  in  most  in- 
stances one  of  little  or  no  difficulty.  Papillomatous  growths,  however, 
upon  the  mucous  membrane  of  the  mouth  and  tongue  must  not  be  con- 
founded with  venereal  warts — condyloma — nor  with  epithelioma,  as 
errors  of  this  character  might  be  productive  of  serious  consequences. 
In  children  and  youths,  condyloma  is  the  only  affection  with  which  it 
can  be  confounded,  as  epithelioma  is  not  a  disease  of  early  life.  In 
adults,  especially  men,  there  is  danger  that  the  more  serious  form  of 
epithelial  tumor  may  be  diagnosed  as  papilloma.  This  would  be  an 
exceedingly  grave  error,  endangering  the  life  of  the  patient. 

The  diagnosis  in  the  latter  period  of  life  becomes  still  more  diffi- 
cult, on  account  of  the  tendency  at  this  period  of  the  simple  form  of  the 
disease  being  transformed  into  the  malignant  type. 


TUMORS    OF   THE    FACE,    MOUTH,    AND    JAWS. 


467 


Tycaimcnt. — The  treatment  of  papillomata  is  ablation  with  the 
knife  or  scissors  and  thorough  cauterization  of  the  base,  either  with 
stick  nitrate  of  silver,  chlorid  of  zinc,  or  the  galvano-cautery.  Various 
other  methods  are  recommended  for  their  removal,  such  as  the  applica- 
tion of  \'ienna  paste,  ligation,  and  galvano-puncture. 

The  treatment  of  the  disease  when  occurring  late  in  life  should  be 
more  heroic.  A  considerable  portion  of  the  surrounding  tissue  should 
be  removed  with  the  tumor,  as  by  such  treatment  the  dangers  of  a  re- 
currence, should  the  growth  prove  to  possess  malignant  tendencies, 
would  be  much  less  than  though  a  minimum  amount  of  tissue  had  been 


Fig.  1 98. 


Cutaneous  Horn.    Madame  Dimanche.     (After  Sutton.) 

scarified.  Besides  this,  the  surgeon  would  have  the  satisfaction  of  feel- 
ing that  if  he  had  made  an  error  in  his  diagnosis,  it  was  upon  the  side 
of  the  best  interests  of  the  patient. 

Cornu  Cutaneum — (Horny  tumors  growing  from  the  skin). — 
Another  variety  of  papillomata,  though  one  rarely  seen,  are  the  cutane- 
ous horns. 

In  this  form  of  papilloma  the  tumor  is  composed  almost  exclu- 
sively of  epithelial  cells  from  the  horny  layer  of  the  skin,  which  ordinar- 
ily, after  serving  their  purpose,  are  desquamated,  but  which  for  some 
reason  remain  attached  to  the  tumor-matrix,  gradually  increasing  until 
they  form  projections  or  horns  of  various  lengths,  from  -J  inch  to  12  or 
more  inches.  It  is  possible  that  the  matrix  of  the  cutaneous  horn 
furnishes  a  cem.ent  substance  (Senn)  which  fixes  the  epithelial  cells, 
and  thus  prevents  their  removal  by  desquamation. 


468 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


These  tumors  have  their  origin  in  sebaceous  glands,  warts,  cicatri- 
cial tissue,  and  nails.  They  are  most  frequently  located  upon  the  scalp, 
temple,  forehead,  eyelid,  nose,  lip,  cheek,  and  shoulder,  and  upon  vari- 
ous other  portions  of  the  body.  One  of  the  most  remarkable  cases  of 
cutaneous  honis — sebaceous — is  that  of  ]\Iadame  Dimanche,  who  had  a 
long  horn  growing  from  the  forehead,  and  another  smaller  one  from 

Fig.  199. 


Horns  Growing  from  the  Scar  of  a  Burn.     (Cruveilhier,  after  Sutton.) 


the  right  cheek  (Sutton) ;  a  wax  cast  of  whose  face  is  preserved  in  the 
museum  of  the  Royal  College  of  Surgeons,  England.  (Fig.  198.)  A 
very  remarkable  cicatricial  horn  arising  from  the  palmar  surface  of  the 
hand  following  a  severe  burn,  and  which  reached  such  an  enormous 
size  that  amputation  became  necessary,  was  reported  by  Cruveilhier. 
(Fig.  199.)  Mr.  Edwards,  of  London,  also  reported  a  similar  one 
originating  in  a  burn  which  occurred  sixty-five  years  previously  (Sut- 
ton).    The  tumors  in  both  of  the  latter  cases  were  multiple.      Wart 


TUMORS    OF    THE    FACE,    MOUTH,    AND    JAWS.  469 

horns  are  prone  to  degeneration  at  their  base,  and  in  elderly  persons 
they  may  not  infrequently  terminate  in  epithelioma. 

To  determine  the  origin  of  cutaneous  horns,  Sutton  divides  them 
longitudinally.  The  existence  of  a  cyst  at  the  base  proves  them  to  be 
of  sebaceous  origin ;  its  absence,  of  warty  origin.  The  nail  horns  need 
no  description  in  these  pages,  as  they  are  only  met  with  in  connection 
with  the  fingers  and  toes. 

.  Treatment. — Cutaneous  horns,  as  a  rule,  are  not  very  firmly  at- 
tached to  the  skin,  and  are  usually  easily  detached  with  the  lingers. 
When  too  firmly  adherent  for  removal  by  this  means,  they  can  be  ex- 
cised. Occasionally  amputation  of  the  member  upon  which  it  grows 
may  be  necessary.  After  removal  of  the  growth,  the  base  should  be 
thoroughly  cauterized  to  destroy  any  remnants  of  the  tumor  which 
might  remain,  and  thus  prevent  a  recurrence.  When  epithelioma  at- 
tacks the  base  of  the  horn,  early  and  heroic  treatment  is  demanded. 


CHAPTER    XLVII. 
EPITHELIAL  TUMORS    (Continued). 

Adenomata. 

Definition. — Adenoma  (Gr.  a8>^v,  gland,  and  ofm.^  tumor).  An 
adenoma  is  a  tumor  that  has  developed  from  a  gland,  or  is  constructed 
after  the  type  of  a  secreting-  gland. 

An  adenoma  is  a  true  neoplasm,  and  should  not  be  confounded 
with  retention  cysts,  or  with  glands  enlarged  by  overgrowth,  overwork, 
or  chronic  inflammation,  for  these  conditions  are  in  no  sense  new  for- 
mations. Although  we  might  on  first  thought  be  inclined  from  the 
definition  of  the  term  adenoma,  to  class  all  glandular  enlargements  in 
which  there  was  an  abnormal  multiplication  of  the  glandular  elements, 
as  adenomata,  yet  upon  a  consideration  of  the  evident  physiologic 
impotence  of  new  growths  to  produce  a  normal  gland-secretion 
(Ziegler),  and  the  lack  of  anatomic  relations  with  surrounding  tissues, 
such  a  classification  would  be  manifestly  incorrect.  Senn  says,  "In 
the  strictest  etiologic  and  pathologic  sense,  the  term  should  be  limited 
to  glandular  tumors  containing  adenomatous  tissue  produced  from  a 
tumor-matrix  independently  of  the  pre-existing  glandular  tissue." 

The  adenomata  are  less  distinctly  defined  in  structure  than  most  of 
the  other  neoplasms.  The  transitions  between  glandular  hyperplasias 
and  glandular  tumors  are  manifold.  The  former  are  many  times  dis- 
tinguished with  difficulty  from  certain  inflammatory  swellings,  while 
the  latter  not  infrequently  present  transitional  forms  which  are  almost 
identical  with  epithelioma.  The  anatomic  and  histologic  structures  of 
these  growths  are  sometimes  most  difficult  to  define  microscopically, 
on  account  not  only  of  the  transitional  changes  just  referred  to,  but  also 
because  of  other  changes  occurring  within  them  and  in  the  surround- 
ing tissues,  such  as  hemorrhage,  edema,  and  various  degenerative 
metamorphoses,  like  the  fatty  mucoid,  colloid,  fibroid,  and  hyaline 
(Figs.  200,  201)  ;  the  formation  of  papillary  and  villous  growths,  and 
the  development  of  cysts. 

Adenomata  of  the  intestinal  tract  are  very  prone  to  present  a  ma- 
lignant degeneration,  or  at  least  have  the  properties  of  malignant  tu- 
mors (Councilman),  viz:  of  infecting  surrounding  parts,  and  producing 

470 


EPITHELIAL   TUMORS. 


471 


metastases.  When  the  disease  is  located  in  the  stomach  or  intestines, 
the  several  coats  are  successively  attacked,  often  resulting  in  perfora- 
tion. Zicgler  applied  the  term  adenoma  destruens  to  this  variety  of 
adenomata. 

The  trite  adenomata  can  generally  be  distinguished  from  the  glan- 
dular hyperplasias  by  certain  well-marked  signs  of  consistence,  color, 
and   structure,   as   compared   with   the    surrounding   tissue.      These 


Fig.  200. 


Hyaline 
degeneration. 


* 

gfl 

■  rSfj 

H 

"^- 

1 

■#.  ■- . 

'-' 

•  •  '^P^^ 

^^ 

.   ■  ■«      ■    '  ■     ,              ■;. 

%-    :'*'i;,^J^ 

.'o^'^^SwH 

^BBB 

m 

s 

w 

<..  '  .jJgfl 

m 

:^'MKj^W^r^ 

Wi:.^^.- 

^B^K 

Inflammatory 
tissue. 


Hyaline  Degeneration  from  Inflammation  of  Lymphatic  Gland  of  the  Neck. 

tumors  are  of  themselves  benign  growths,  but  the  tendency  to  pass  into 
cancerous  formation  must  be  constantly  borne  in  mind.  Pure  aden- 
oma is  a  rare  affection. 

The  structural  peculiarity  of  an  adenoma  is  the  presence  of  epithe- 
lial cell-elements  which  are  arranged  after  the  order  of  secreting 
glands,  and  supported  by  a  connective-tissue  stroma.  (Fig.  202.)  In 
some  forms  of  adenoma  the  epithelial  element  predominates,  while  in 
others  the  connective  tissue  is  largely  in  excess.  Most  of  these  neo- 
plasms are  mixed  tumors,  having  other  elements, — fibrous,  myxoma- 
tous,   sarcomatous,    carcinomatous,    etc., — in    combination    with    the 


472 


SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 


glandular  structure.  Tumors  formed  in  this  manner  are  designated  as 
fibro-adenoma,  myxo-adenoma,  etc.  Fig.  203  shows  the  histologic 
.structure  of  fibro-adenoma. 

Fig.  201. 


Fibroid  Degeneration — Mammae.    ><  50. 


Fig.  202. 


Adenoma  (Polypus)  of  the  Rectum,  showing  the  Glands  of  the  Tumor.    X  350. 

(After  J.  D.  Hamilton.) 

a,  gland  lined  by  columnar  epithelium  ;  b,  stroma  of  the  tumor. 


EPITHELIAL   TUMORS. 


473 


Adenomata  occur  as  congenital  tumors ;  as  developments  of  early 
life,  and  they  occasionally  occur  during  any  period  of  adult  life.  They 
are  found  in  such  tissues  as  the  breast,  the  skin,  the  mucous  membrane, 
the  kidneys,  the  liver,  the  thyroid  and  parotid  glands.  Although  aden- 
oma is  not  a  common  form  of  tumor,  it  has  a  wide  distribution,  being 
found  in  nearly  all  portions  of  the  body  which  have  had  their  origin  in 
the  epiblastic  and  hypoblastic  layers  of  the  germinal  disk.  Inasmuch 
as  adenomata  are  found  in  all  of  the  glandular  structures  of  the  body, 

Fig.  203. 


FiBRO-ADENOMA.       X'    50. 


it  should  be  noticed,  as  a  marked  peculiarity,  that  the  cells  which  com- 
pose these  neoplasms  closely  resemble  the  individual  structure  of  the 
gland  or  duct  with  which  they  are  associated. 

The  adenomata  usually  appear  as  knot-like  growths  in  the  sub- 
stance of  glands,  in  glandular  epithelium,  or  epidermic  tissues  (Zieg- 
ler);  their  most  common  seat  being  such  glands  as  the  mamma,  the 
ovary,  the  parotid,  the  thyroid,  and  the  liver;  also  in  the  glands  of  the 
mucous  membrane  of  the  rectum,  the  intestines,  and  the  uterus  (Sut- 


474  SURGERY    OF    THE    FACE,    MOUTH,   AND    JAWS. 

ton).     They  may  be  sessile  or  pedunculated,  the  form  being  governed 
by  their  character  and  location. 

The  development  of  adenoma  is  not  necessarily  confined  to  pre- 
existing glandular  structures,  as  they  may  be  formed  in  locations  where 
glands  do  not  normally  exist.  The  explanation  of  the  origin  of  the 
tumors  in  such  locations  is  to  be  found  in  the  displacement  and  isola- 
tion of  embryonic  cells  during  fetal  life,  or  in  the  formation  of  a  "tumor 
matrix"  of  embryonic  cells  within  a  supernumerary  or  accessory  gland. 
(Senn.) 

The  glandular  tumors  vary  considerably  in  size,  ranging  from  a 
pea-like  nodule  to  as  large  as  a  man's  head,  in  locations  like  the  female 
breast;  while  cysto-adenoma  of  the  ovaries  weighing  thirty  to  forty 
pounds  is  not  uncommon. 

The  adenomata  are  developed  in  two  forms:  the  acinous  and  the 
tubular.  Acinous  adenoma  simulates  the  structure  of  the  conglomer- 
ate glands.  The  stroma  varies  in  amount.  If  the  tumor  is  hard,  the 
stroma  is  abundant;  if  soft,  it  is  scanty.  The  blood-vessels  are  located 
in  the  stroma,  and  each  lobule  or  tubule  is  supplied  from  these  with  a 
capillary  net- work  of  vessels,  while  the  lobules  or  tubules  are  lined  with 
flat  epithelial  cells.  These  tumors  are  usually  associated  with  the  con- 
glomerate glands. 

Tubular  adenoma  closely  resembles  the  simple  tubular  glands. 
The  epithelial  cells  are  arranged  in  single  or  stratified  layers  within  the 
tubule,  while  an  open  space  is  left  in  the  center.  This  form  springs 
from  mucous  membranes  which  have  glands  of  the  tubular  form.  It  is 
most  commonly  associated  with  glands  of  this  construction  located  in 
the  intestinal  canal,  and  especially  in  the  rectum.     (Fig.  204.) 

Causes. — The  causes  may  be  divided  into  predisposing  and  excit- 
ing. 

The  predisposing  or  essential  cause  is  the  presence  of  a  tumor- 
matrix  of  embryonic  cells  which  have  been  misplaced  and  isolated 
during  fetal  development.  The  tumor-matrix,  however,  may  remain 
indefinitely  in  a  quiescent  and  undeveloped  state,  until  stimulated  to 
activity  by  some  abnormal  condition  of  its  surroundings,  or  by  a  direct 
injury. 

The  exciting  or  active  causes  of  their  development  are  traumatic 
injuries,  irritation  of  various  forms,  and  acute  or  chronic  inflamma- 
tions. Organs  which  are  the  seat  of  periodic  congestions,  like  the 
mamma,  the  ovary,  the  uterus,  and  the  prostate  gland,  are  the  most 
common  location  of  these  tumors;  while  in  the  mucous  membranes 
which  are  most  liable  to  catarrhal  ai=fections,  like  the  nasal  passages 
and  the  rectum,  these  neoplasms  are  of  common  occurrence. 

Prognosis. — ^The  prognosis  of  true  adenoma  depends  principally 
upon  the  location  in  which  it  is  developed.     It  is  benign  in  its  char- 


EPITHELIAL   TUMORS. 


475 


acter,  and  when  completely  removed  does  not  return.  It  differs  from 
the  malignant  tumors  in  that  it  does  not'  infect  the  lymph-glands  in  its 
neighborhood,  neither  does  it  cause  metastatic  deposits.  It  frequently 
attains  an  enormous  size,  and  when  located  in  the  ovaries,  or  m  the 
thyroid  glands,  sometimes  causes  a  fatal  termination.  Death  in  these 
cases  is  caused  by  mechanical  complications,  usually  of  pressure  upon 
important  viscera  or  vital  organs.  Adenoma  is  inclined  to  undergo 
degenerative  changes,  particularly  hyaline,  colloid,  cystic,  and  fatty  de- 
generation. It  has  also  a  tendency  in  the  later  years  of  life  to  take  on 
malignant  transformations. 


Fig.  204. 


SECTION   OF   AN    ADENOMA    FROM    A    CHILD'S    RECTUM.      HIGHLY   MAGNIFIED.       ( After  SuttOD., 

Adenoma  of  the  Skin. — In  adenomata  of  the  skin,  the  tumors 
are  found  associated  with  the  sweat  or  sudoriparous  glands  and  the 
sebaceous  glands.  (Fig.  205.)  Adenoma  of  the  sweat-glands  is  seen  in 
various  parts  of  the  body,  but  most  frequently  upon  the  face.  These 
tumors  may  vary  in  size  from  a  pea  to  a  walnut,  or  may  even  be  as 
large  as  the  fist.  In  appearance  they  are  commonly  small,  soft  tumors, 
with  nodular  surface  and  a  dirty,  grayish-white  color.  Generally  they 
are  circumscribed,  but  occasionally  they  form  diffuse  or  ill-defined 
growths.  The  skin  over  them  is  at  first  but  little  changed,  but  later  it 
is  often  ulcerated  (Wagner),  and  they  have  been  mistaken  for  angeio- 
mata.     They  are  slow  of  growth,  and  are  a  somewhat  rare  form  of  neo- 


476 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


plasm.     A  cut  section  of  such  a  growth  discloses  coils  of  dilated  ducts, 
from  which  can  be  pressed  degenerated  epitheliimi  (Warren). 

The  growth  of  the  tumor  seems  in  some  instances  to  take  place 
from  the  deeper  portion  of  the  tubule  of  existing  sweat-glands,  while 
in  others  it  seems  to  be  quite  independent  of  any  glandular  origin. 

Fig.  205. 


Horizontal  Section  of  Human  Scalp,  showing  Glandular  Structure  and  Hair.    X  50. 

(T.  Charters  White.) 


Thierfelder  observed  a  case  in  which  the  tumor  had  its  origin  in  the 
diploe  of  the  cranial  bones,  but  communicated  with  the  skin.  This 
connection  would  point  to  the  probability  that  it  originated  in  the  skin. 
Adenoma  of  the  sebaceous  glands  appears  upon  the  face  in  the 
form  of  papules,  which  are  usually  of  congenital  origin  (Warren),  and 
form  little,  roundish,  convex  tumors,  the  size  varying  from  that  of  a 
pin-head  to  that  of  a  pea,  often  bright  crimson  in  color.     The  small 


EPITHELIAL   TUMORS. 


477 


tumors  assume  the  form  of  a  sebaceous  gland,  but  in  the  larger  ones 
the  glandular  tubule  (Senn)  forms  a  convoluted  mass.  (Fig.  206.) 
The  nose  is  a  favorite  seat  for  the  development  of  this  form  of  tumor. 
Tumors  found  in  this  location  were  formerly  called  lipomata,  but  they 
are  now  known  in  many  instances  (Sutton)  to  be  sebaceous  adenomata. 
This  form  of  adenoma  is  quite  prone  to  ulcerate,  and  occasionally  to 
calcify  (Eve). 

Diagnosis. — In  diagnosing  adenoma  of  the  skin,  there  is  as  a  rule 
very  little  difficulty,  for  the  especial  features  of  the  disease  are  well  de- 
fined, and  the  growth  always  occurs  in  regions  occupied  by  sudoripar- 
ous or  sebaceous  glands.  The  diseases  which  may  be  mistaken  for 
adenoma  of  the  skin  are  epithelioma,  molluscum  epitheliale,  and  lipoma. 


Fig.  206. 

o\\Wv>l<J^^1'ii'^i\\|(iniri,niiii/,f,^ 


Large  Sebaceous  Adenoma  involving  the  Pinna.     (After  Sutton.) 

Prognosis. — The  prognosis  in  uncomplicated  adenoma  of  the  skin- 
is  always  favorable;  recurrence  after  extirpation  is  rare. 

Treatment. — The  treatment  is  surgical,  and  consists  of  the  removal 
of  the  tumor.  This  is  accomplished  in  most  cases  with  ease,  as  these 
tumors  are  usually  encapsulated,  and  are  readily  shelled  out  or  enu- 
cleated. 

Adenoma  of  the  Mucous  Membrane. — Adenoma  of  the  mucous 
membrane  appears  in  two  forms.  One  is  confined  to  the  mucosa  or 
mucous  membrane  proper;  the  other  involves  the  sub-niucosa,  or  the 
submucous  connective  tissue,  and  from  this  it  extends  to  adjacent  tis- 
sues and  organs. 

The  first  variety  is  expressed  in  the  form  of  polypoid  growths,  the 


478  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

Structure  of  which  closely  simulates  the  glandular  arrangement  of  the 
membrane  from  which  it  springs,  the  difiference  being  that  the  glandu- 
lar elements  are  larger,  more  numerous,  and  less  regular  (Ziegler)  than 
m  the  normal  tissue.  (Fig.  207.)  This  form  Ziegler  classes  as  glandu- 
lar hyperplasias.  The  second  variety  he  designates  as  adenoma  des- 
truens. This  latter  form  also  simulates  the  glandular  structure  of  the 
mucous  membrane,  but  differs  from  the  other  variety  in  its  mode  of  de- 
velopment and  its  tendencies  to  involve  surrounding  tissues  and  cause 

metastases. 

Fig.  207 


Adenoma— Benign.    X  50. 

The  first  variety  is  frequently  associated  with  the  Schneiderian 
mucous  membrane  in  the  form  of  pedunculated  growths  in  the  nasal 
passages  and  vault  of  the  pharynx.  These  growths  may  be  in  the  form 
of  mucous  or  gelatinous  polypi,  or  they  may  be  true  adenomata.  (Fig. 
208.)  The  majority  of  polypi  are  not  true  adenoid  growths,  but  in- 
flammatory enlargements  or  hyperplasias  of  the  glandular  elements  of 
the  mucous  membrane.  The  adenoid  vegetations  described  by  Meyer, 
Cohn,  and  others,  are  not  of  very  frequent  occurrence,  but  a  condition 
of  hyperplasia  of  the  glandular  elements  of  the  pharyngeal  tonsil, 
which  is  expressed  in  nodular  enlargements  or  polypoid  excrescences, 
is  quite  common.  The  true  adenoid  growths  sometimes  attain  to  con- 
siderable size.  In  the  nasal  passages  they  have  been  known  to  fill 
these  passages  and  the  adjacent  sinuses,  causing  distention  and  facial 
deformitv. 


EPITHELIAL    TUMORS. 


479 


Cystic  degeneration  of  the  mucous  glands,  of  the  hning  membrane 
of  the  nasal  passages,  and  of  the  antrum  of  Highmore,  is  occasionally 
seen.  This  form  of  the  disease,  however,  is  more  common  in  the  an- 
trum than  in  the  nose.  Occasionally  the  glands  are  enlarged  and  mul- 
tiplied as  in  adenoma,  resulting  in  adciw-myxoma.  The  adenoid 
growths  of  the  antrum  not  infrequently  manifest  malignant  tendencies, 
ending  in  adcno-carcinonia.  The  malignancy  of  this  form  of  tumor  is 
equal  to  that  of  the  most  malignant  type  of  carcinoma,  and  it  is  the 
opinion  of  the  writer  that  many  of  the  malignant  growths  of  the  antrum 

Fig.  208. 


Nasal  Polypus.— Myxomatous  Tissue— showing  Ciliated  Epithelial  Cells.    X  50. 


that  are  classed  as  carcinoma  and  epithelioma  have  their  origin  in 
adenoid  growths,  associated  with  the  lining  mucous  membrane  of  this 
sinus. 

The  destructive  adenoma  ("adenoma  destruens")  is  a  soft,  mar- 
rowy tumor,  taking  the  form  of  capillary  or  fungous  outgrowths  (Zieg- 
ler),  or  of  an  extensive  thickening,  and  a  slightly  raised  surface  of  the 
afifected  portion  of  the  mucous  membrane.  The  new-formed  tissue 
shows  a  marked  tendency  toward  degeneration  in  the  formation  of 
ulcerated  surfaces.  The  ulcers  appear  with  raised,  "rampart-like" 
edges,  and  a  soft,  infiltrated  base,  and  the  surrounding  tissue  is  fre- 
quently studded  with  nodular  growths.  This  form  is  most  frequently 
seen  in  the  stomach  and  intestinal  mucous  membrane. 


480  SURGERY    OF   THE    FACE,    MOUTH,   AND   JAWS. 

Adenoma  of  the  buccal  mucous  membrane  rarely  attains  dimen- 
sions larger  than  a  pea  or  a  small  bean,  though  occasionally  it  may 
reach  a  much  larger  size.  They  are  generally  true  adenomata,  and  are 
most  often  seen  upon  the  lower  lip  and  cheeks, — rarely  upon  the  upper 
lip.  These  tumors  are  of  slow  growth,  and  several  years  may  elapse 
before  they  attain  a  size  sufficient  to  cause  inconvenience. 

Diagnosis  and  Symptoms. — Adenoma  of  the  buccal  mucous  mem- 
brane appears  as  single,  smooth  or  nodulated  enlargements  beneath 
the  mucous  membrane,  firm  and  non-elastic  to  the  touch,  usually  ses- 
sile, and  but  slightly  adherent  to  the  overlying  membrane  or  to  the  tis- 
sues beneath,  and  generally  encapsulated.  They  are  not  painful  unless 
ulceration  or  cancerous  degeneration  takes  place.  The  only  promi- 
nent symptom  in  the  benign  form  of  the  disease  is  one  of  incon- 
venience, occasioned  by  its  size  or  location,  or  both. 

Adenoma  of  the  Palate. — Adenoma  is  more  frequent  in  the  palate 
than  in  other  portions  of  the  oral  cavity.  The  growths  appear  as 
smooth  or  nodulated  tumors  beneath  the  mucous  membrane;  in  other 
respects  they  are  like  those  found  upon  the  lips  and  cheeks.  They  are 
located  upon  either  side  of  the  median  line,  and  when  they  are  of  large 
size  cause,  as  a  first  evidence  of  their  presence,  a  slight  nasal  twang  of 
the  voice  (Cohen).  Later  there  is  a  gradually  increasing  mechanical 
difficulty  in  swallowing,  at  first  of  liquids  only;  later  of  all  ingesta.  Fig. 
209  shows  the  histologic  structure  of  a  pure  adenoma  of  the  palate. 

Diagnosis  and  Symptoms. — The  development  of  neoplasms  and  in- 
flammatory swellings  in  the  velum  palati  gives  rise  to  certain  definite 
symptoms,  viz :  dysphagia,  cough,  difficulty  of  breathing,  changes  in  the 
resonance  of  the  voice,  which  acquires  a  peculiar  nasal  twang  due  to 
the  imperfect  occlusion  of  the  soft  palate  with  the  vault  of  the  pharynx. 
Pain  is  rarely  associated  with  the  growth  of  these  tumors,  or  with  the 
dysphagia  incident  to  their  presence. 

Prognosis. — The  prognosis  of  adenoma  of  the  oral  mucous  mem- 
brane and  of  the  palate  is  usually  favorable.  In  the  destructive  variety 
of  the  affection  the  prognosis  would  be  unfavorable,  as  metastases  and 
recurrence  are  likely  to  follow.  In  the  benign  form  of  the  disease, 
operation  gives  good  results,  as  the  growths  can  be  removed  in  their 
entirety. 

Treatment. — The  treatment  of  adenoma  of  the  palate  consists  of 
excision,  evulsion,  or  constriction.  The  character  of  the  operation 
should  be  governed  by  the  pathologic  tendencies  of  the  growth,  its 
shape,  and  its  accessibility.  Polypi  of  the  nasal  passages  may  be 
removed  by  the  wire  snare  or  ecraseur.  (Figs.  210,  211.)  The  ma- 
jority of  these  tumors  are  encapsulated,  and  are  easily  removed  by  a 
single  or  double  incision  through  the  mucous  membrane.  A  single 
incision  only  is  required  for  growths  of  small  size;  the  double  incisions 


EPITHELIAL    TUMORS. 


481 


which  are  made  at  right  angles  to  each  other,  are  necessary  for  the 
removal  of  the  larger  growths.  The  existing  adhesions  are  then  torn 
or  dissected  away,  the  tumor  turned  out  of  its  capsule,  and  the  wound 
closed  with  sutures.  In  the  region  of  the  palate  hemorrhage  from  the 
posterior  palatine  artery  may  sometimes  prove  troublesome,  but  it  can 
be  controlled  by  a  tampon,  ice,  the  various  hemostatics,  or  by  the 
electro-thermal  cautery.  The  after-treatment  should  consist  of  fre- 
quent irrigation  of  the  mouth  with  antiseptic  solutions. 

Fig.  209. 


rii 

Htt 

^^ 

^^g 

m 

n 

H 

^S 

i 

wA 

I 

1 

1 

p 

1 

H 

^1 

1 

1 

1 

^m 

^ 

w 

s^ 

M 

Bi 

^ 

^^^1 

Adenoma — Pure — of  Palate. 


Adenoma  of  the  Tongue  is  an  exceedingly  rare  affection.  Butlin, 
in  his  work  on  "Diseases  of  the  Tongue,"  considers  it  "so  rare  that 
no  general  account  can  be  written  of  it."  Of  the  four  cases  which  he 
mentions,  two  occurred  in  persons  near  middle  life,  the  third  in  a 
girl  of  sixteen,  and  the  fourth  in  a  new-born  babe  which  lived  only 
sixteen  hours;  death  being  due  to  pressure  of  the  growth  upon  the 
larynx,  the  tumor  having  developed  in  the  base  of  the  tongue.  In  one 
the  tumor  was  situated  well  back  upon  the  dorsum  of  the  tongue;  in 

32 


482 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


another  it  was  located  upon  the  under  side  of  the  tip  of  the  tongue,  but 
in  the  case  of  the  girl  the  location  of  the  growth  was  not  mentioned. 

Rosenberg  thinks  adenoma  of  the  tongue  is  very  rare.  Accord- 
ing to  Thaon  and  Larabie,  these  tumors  are  really  mixed  epitheliomas. 
The  microscope  reveals  a  connective-tissue  net-work  or  stroma  which 

Fig.  210. 


Points  for  Wire  Snare. 


Fig.  211. 


Wire  Ecraseur. 


embraces  the  epithelial  infiltration.  In  the  early  history  of  these 
growths  the  epithelial  elements  are  in  excess;  later  the  connective-tis- 
sue elements  predominate,  which  in  all  probability  accounts  for  the 
relative  innocence  of  these  neoplasms.  Larabie  advises,  on  account  of 
the  possibilities  of  these  growths  developing  true  carcinomatous  ele- 
ments, early  and  free  excision  of  the  tumor. 

Diagnosis  and  Symptoms. — There  are  no  diagnostic  signs  or  symp- 
toms which  are  distinctive  of  adenoma  of  the  tongue,  and  no  means 


EPITHELIAL    TUMORS.  483 

whereby  an  exact  diagnosis  can  be  made,  except  by  removal  of  a 
portion  of  the  tumor  and  subjecting  it  to  a  microscopic  examination. 
Adenoma,  fibroma,  and  Hpoma  are  not  readily  distinguished  from  one 
another  while  in  situ,  and  may  therefore  be  easily  mistaken  one  for 

the  other. 

The  symptoms  which  are  common  to  enlarged  glands  and  the 
various  tumors  which  may  be  located  upon  the  dorsum  of  the  tongue 
are  a  sensation  of  a  foreign  body  in  the  throat,  irritation,  cough, 
dyspnea,  dysphagia,  fatigue  of  the  voice,  and  painful  deglutition  in 
those  cases  associated  with  inflammatory  conditions  of  the  glands  or 
of  the  neoplasms. 

Prognosis. — The  prognosis  of  adenoma  of  the  tongue  is  good. 
Early  extirpation  is  demanded  as  a  precaution  against  the  develop- 
ment of  malignant  disease,  and  to  relieve  the  local  symptoms. 

Treatment. — The  treatment  consists  of  enucleation  or  excision  of 
the  tumor.     The  removal  of  a  sufficient  amount  of  the  surrounding 
tissue  to  insure  a  complete  extirpation  should  always  be  practiced  in 
those  tumors  which  arouse  suspicion  as  to  their  malignant  character. 
Adenoid  tumors  of  the  tongue  are  usually  found  situated  well  back 
upon  the  dorsum  of  the  organ,  which  makes  the  operation  somewhat 
difficult  to  perform.     The  removal  of  these  growths  is  not  essentially 
different  from  the  operation  in  other  locations  of  the  oral  cavity,  as 
they  are  always  found  encapsulated  and  are  easily  enucleated.     Before 
commencing  the  operation,  the  tongue  should  be  secured  by  passing  a 
strong  ligature  through  the  tip,  the  tongue  being  drawn  well  forward 
and  held  in  that  position  during  the  operation.     The  jaws  should  be 
held  apart  by  means  of  a  mouth  gag.      Hemorrhage  is  sometimes 
troublesome  from  venous  and  capillary  oozing,  but  this  can  usually  be 
controlled  by  pressure  over  the  bleeding  surfaces  with  a  piece  of  gauze 
and  the  finger.     When  the  loss  of  tissue  has  not  been  too  great  to 
permit  of  this,  the  edges  of  the  wound  should  be  brought  together  with 
sutures.     Antiseptic  treatment  of  the  wound  and  of  the  mouth  should 
be  carefully  followed  to  prevent  suppuration  and  secondary  septic 

infection. 

Adenoma  of  tlie  Salivary  Glands.— Adenoma  of  the  salivary 
glands  is  not  a  common  affection,  but  when  it  does  exist  it  is  asso- 
ciated with  the  parotid  gland.  The  submaxillary  and  the  sublingual 
glands  seem  to  be  quite  exempt  from  this  form  of  tumor.  Weber  is 
of  the  opinion  that  even  the  parotid  gland  is  very  rarely  the  seat 
of  true  adenoma.  Billroth  does  not  think  that  true  adenoma  ever 
exists  in  the  parotid  gland,  but  that  all  adenoid  growths  located  in  this 
gland  are  mixed  tumors,  adeno-cystoma,  adeno-chondroma,  adeno- 
carcinoma, etc.  Pure  adenoma,  however,  has  been  found  in  the  paro- 
tid gland.    \A'arren  describes  a  perfectly  formed  adenoma  in  the  parotid 


484  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

gland  of  the  size  of  a  hen's  egg,  and  quite  soft  in  structure.  In  this 
respect  it  differed  from  the  ordinary  tumors  found  in  this  gland. 

Parotid  adenoma  most  frequently  occurs  in  youth  and  early  adult 
life, — between  the  fifteenth  and  thirtieth  years  of  age  (Sutton). 

Diagnosis  and  Syinptoins. — Adenoma  of  the  parotid  occurs  as  dis- 
tinctly encapsulated  tumors.  They  are  not  painful,  may  arise  in  any 
part  of  the  gland,  are  of  slow  growth,  and  rarely  exceed  a  pigeon's  tgg 
in  size.  Positive  diagnosis  is  dii^cult  to  make  except  by  a  micro- 
scopic examination  after  the  operation. 

Cystic  degeneration  is  common,  and  papillary  excrescences  often 
develop  upon  the  cyst-walls  and  project  into  the  tumor.  Microscopic 
examination  of  these  excrescences  shows  them  to  be  composed  of  the 
same  elements  as  the  secreting  tissue  of  the  gland.  These  tumors  have 
a  strong  resemblance  to  the  adenomata  found  in  the  thyroid  gland. 
Usually  they  are  encapsulated,  and  can  be  readily  enucleated  with  little 
or  no  permanent  damage  to  the  gland. 

Prognosis. — The  prognosis  is  favorable  in  uncomplicated  adenoma 
of  the  salivary  glands.  In  adenoma  with  malignant  tendencies  it 
would  be  very  unfavorable.  In  the  latter  case,  early  and  complete 
extirpation  of  the  entire  gland  is  the  only  means  of  saving  the  life  of 
the  patient. 

Treatment. — In  operating  for  the  removal  of  adenoma  of  the 
parotid,  the  incisions  should  be  made  with  especial  reference  to  the 
preservation  of  Stenson's  duct  without  mutilation,  and  with  due 
regard  to  the  location  of  the  branches  of  the  facial  nerve.  The  pos- 
terior edge  of  the  gland  lies  in  close  relation  to  the  external  carotid, 
superficial  temporal,  transverse  facial,  internal  maxillary,  and  internal 
carotid  arteries,  the  external  jugular  vein  and  its  anastomosing  sub- 
maxillary branch,  and  the  internal  jugular  vein. 

In  cutting  down  upon  the  tumor,  a  thin  portion  of  the  gland  may 
be  incised,  and  as  a  result  salivary  fistula  may  follow  the  operation. 
Usually,  however,  if  Stenson's  duct  has  not  been  injured,  the  discharge 
of  saliva  through  the  wound  is  only  a  temporary  matter. 

The  extirpation  of  the  gland  for  the  removal  of  malignant  growths 
may  require  the  ligation  of  the  external  carotid  artery  and  of  the  exter- 
nal jugular  vein. 


CHAPTER    XLVIII. 


CYSTOMATA. 


Definition. — Cyst  (Or.  KiWts,  a  pouch),  a  cavity  containing  fluid, 
and  surrounded  by  a  capsule. 

"A  cyst  is  a  cavity,  either  natural  or  newly-formed,  filled  with  a 
material  more  or  less  fluid,  or  pulpaceous,  and  surrounded  by  an 
investing  membrane  or  capsule,  which  separates  it  from  the  surround- 
ing tissues." 

Fig.  212. 


Simple  Cystoma. 


Cysts  may  be  divided  into  two  groups:  P'irst,  those  which  are 
formed  by  the  dilatation  of  cavities  already  in  existence — the  natural 
cavities  of  the  body — or  which  are  formed  by  a  tissue  already  present 
in  the  body,  by  softening  or  degeneration;  and,  second,  those  which 
are  the  result  of  new  formations — neoplasms — which  press  apart  the 
normal  tissues  and  form  cavities  in  locations  where  they  did  not  pre- 
viously exist.     (Fig.  212.) 

Virchow  makes  three  divisions  of  the  first  group,  according  to 

485 


486  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

the  manner  in   which   the   fihing  of  these   cavities   takes  place,  viz: 
Extravasation  cysts,  Exudation  cysts.  Retention  cysts. 

Senn  would  restrict  the  use  of  the  term  "cystoma"  to  those  cystic 
tumors  whose  cyst-wall  is  produced  from  a  matrix  of  misplaced  em- 
bryonic cells,  and  whose  contents  are  the  product  of  tissue-prolifera- 
tion of  the  cells  which  line  the  cyst-wall.  This  excludes  all  other 
forms  of  cysts  except  those  which  have  originated  independently  of 
pre-existing  cavities  or  glandular  structures,  and  which  are  in  the 
strictest  sense  new  formations. 

The  cystomata  are  usually  classed  as  formations  belonging  to 
the  epiblastic  and  hypoblastic  group  of  tumors.  In  a  strictly  histo- 
logic sense,  only  the  cystic  neoplasms  should  be  placed  in  this  group, 
but  from  a  clinical  standpoint  all  forms  of  cysts  might  be  included  in  it. 
An  examination  of  the  cyst-wall  shows  the  inner  surface  to  be  lined 
with  epithelium  or  endothelium,  according  to  its  mode  of  origin. 

The  epithelial  cysts  arise  from  distention  of  epithelial  cavities 
already  in  existence  (Ziegler).  A  glandular  cyst  caused  by  the  closure 
of  its  duct  is  an  instance  in  point.  The  secretion  which  collects  behind 
the  obstruction  dilates  the  gland,  forming  a  cyst,  which  is  filled  with 
an  altered  secretion.  These  are  termed  cysts  of  retention,  and  are 
found  associated  in  the  oral  cavity  with  the  salivary  and  mucous 
glands.  They  are,  however,  more  commonly  seen  in  connection  wdth 
the  mammse,  kidneys,  uterus,  intestines,  and  the  skin. 

Endothelial  cysts  arise  from  distention  of  cavities  in  the  con- 
nective tissue  which  had  a  previous  existence,  like  tendon-sheaths, 
synovial  sheaths,  obstructed  lymphatics,  and  old  hernial  sacs.  These 
are  exudation  cysts.     The  contents  consist  usually  of  lymph. 

Another  form  of  cyst  is  that  which  occurs  in  the  substance  of  solid 
organs,  by  softening  and  disintegration  (Ziegler)  of  defined  portions. 
These  are  termed  cysts  of  disintegration. 

A  fourth  species  of  cyst  is  that  which  is  formed  around  a  foreign 
body  which  has  become  lodged  in  the  tissues,  like  a  bullet,  or  a  para- 
site, like  a  hydatid  (Ziegler),  and  is  the  result  of  a  new-tissue  formation. 
The  classification  generally  used  by  surgeons  is  one  based  upon 
the  character  of  the  contents  of  the  cyst,  viz:  Serous  cysts,  fat  cysts, 
blood  cysts,  mucous  cysts,  grumous  cysts,  etc.  The  extravasation 
cysts  contain  blood;  the  exttdation  cysts,  serum;  while  the  contents  of 
the  retention  cysts  would  vary  with  the  physiologic  function  of  the 
glands  with  which  they  were  associated.  Cysts  found  in  connection 
with  the  teeth  are  usually  exudation  cysts;  those  associated  with  the 
mucous  membrane  and  salivary  glands  are  retention  cysts ;  while  those 
found  in  the  bone  are  the  results  of  new  formations.  The  contents  of 
a  cyst  are  always  inclosed  in  a  capsule  or  investing  membrane,  the 
capsule  being  of  the  same  structure  in  all  essential  particulars  as  that 


CYSTOMATA. 


487 


lining  the  original  cavity  from  which  the  cyst  had  its  origin;  conse- 
quently it  would  vary  with  the  character  of  the  anatomical  structure 
of  the  tissue  in  which  it  was  located.  In  cysts  associated  with  glandu- 
lar structures  there  is  usually  a  well-defined  epithelial  lining,  and  it  is 
a  generally  accepted  fact  that  in  all  cysts  with  a  well-defined  epithelial 
lining  the  cyst  is  not  the  result  of  a  new  formation.  (Fig.  213.)  This 
epithelial  lining  is  subject  to  considerable  change,  as,  for  instance,  when 
greatly  distended,  a  glandular  epithelium  may  resemble  the  lining  of  a 
serous  cavity.    It  may  also  be  lost,  in  great  part,  by  fatty  degeneration. 

Fig.  213. 


MULTILOCULAR    CYSTOMA — GLANDULAR.      X  50. 

The  cyst  membrane  is  made  up  of  firm,  fibrous  connective  tissue,  which 
is  ahvays  more  dense  than  the  surrounding  soft  tissue,  but  in  some 
cases  it  is  much  better  defined  than  in  others.  The  firmness  and  density 
of  the  capsule  renders  it  possible  in  some  cases  to  enucleate  the  cyst 
in  its  entirety.  Inflammatory  adhesions,  however,  often  take  place 
between  the  cyst-wall  and  the  surrounding  tissue,  as  a  result  of  trauma 
or  medication,  which  renders  it  difficult  or  impossible  to  enucleate  it. 
In  cysts  formed  in  the  bones  an  inner  connective-tissue  membrane  is 
usually  present,  and  may  sometimes  be  dissected  out. 

Cysts  may  be  classed  as  either  simple  or  compound.  A  simple  cyst 
is  one  consisting  of  a  single  cavity.  A  compound  cyst  is  composed  of 
an  aggregation  of  simple  cysts,  or  of  many  cavities  which  communi- 
cate more  or  less  freely  with  one  another. 


488  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

A  single  cyst  is  spoken  of  as  a  unilocular  cyst,  and  a  compound  cyst 
as  a  multilocular  cyst.  The  small  cysts  which  occur  upon  the  mucous 
membrane  of  the  cheeks  or  upon  the  tongue,  and  in  connection  with 
the  ducts  of  the  salivary  glands,  are  examples  of  unilocular  retention 
cysts,  while  those  which  occur  in  the  body  of  the  glands  where  the 
acini  of  the  glands  become  distended  and  communicate  with  one  an- 
other are  illustrations  of  multilocular  retention  cysts.  The  simple  and 
compound  cysts  are  frequently  found  in  connection  with  bones.  They 
are  occasionally  met  with  in  the  jaws,  and  sometimes  are  associated 
with  the  teeth.  The  most  common  forms  of  cysts  are  those  associated 
with  some  glandular  organ  in  which  a  tumor  has  formed,  cutting  ofif 
a  portion  of  the  glandular  acini  in  which  the  secretion  accumulates, 
distending  the  individual  sacculi  or  lobuli. 

Age  seems  to  have  little  or  no  effect  upon  the  formation  of  cysts. 
They  may  develop  at  any  age  from  infancy  to  senility,  and  they  are 
sometimes  congenital.  It  has  been  thought  by  certain  authorities 
that  puberty  exerted  an  unfavorable  influence  over  those  organs  con- 
nected with  the  genital  apparatus  in  which  a  predisposition  existed  to 
cystic  formation,  on  account  of  the  increase  in  the  circulation  and 
growth  of  the  parts  at  this  period. 

Cysts,  as  a  rule,  are  slow  in  growth,  but  retention  cysts  and  ex- 
travasation cysts  are  sometimes  very  rapid  in  their  formation,  often 
attaining  an  enormous  size  in  a  short  period  of  time.  The  size  of  cysts 
is  exceedingly  variable,  ranging  all  the  way  from  microscopic  small- 
ness  to  gigantic  dimensions.  The  material  forming  the  contents  of  a 
cyst  is  also  subject  to  a  variety  of  changes.  It  seldom  happens  in  a 
cyst  of  long  standing  that  the  character  of  the  contents  remains  in  an 
unchanged  condition.  In  extravasation  cysts  the  blood  undergoes 
the  various  changes  incident  to  blood  extravasations.  It  is  first  con- 
verted into  a  coagulum,  which  gradually  grows  more  firm  and  dense, 
while  the  coloring  matter  is  deposited  in  the  form  of  amorphous 
coloring  materials  and  crystals.  Occasionally  the  blood  will  remain 
fluid  for  a  considerable  length  of  time,  and  apparently  unchanged  in 
other  respects.  In  serous  cysts  the  liability  to  undergo  change  is  very 
considerable,  the  most  frequent  form  being  that  of  colloid  degenera- 
tion, by  which  the  contents  are  converted  into  a  more  or  less  thick, 
honey-like  fluid.  Cholesterin  and  fatty  crystals  of  great  variety  are 
frequently  found  in  profusion,  while  calcareous  formations  are  not 
uncommon.  Calcareous  formations  may  arise  from  calcification  of 
clots  of  fibrin,  or  they  may  be  the  result  of  direct  precipitation  from 
the  retained  glandular  secretions,  as  sometimes  occurs  in  occluded 
salivary  ducts.  Fatty  degeneration  is  frequently  found  in  slight  degree 
in  the  epithelium  of  cysts,  but  it  is  of  no  particular  conseciuence.  In 
the  higher  degrees  of  metamorphosis  the  epithelium  is  thrown  ofif,  and 


CVSTOMATA.  489 

the  contents  of  the  cyst  become  streaked  or  uniformly  grayish-yellow 
or  yellow.  The  walls  of  the  cyst  may  also  suffer  fatty  degeneration. 
The  capsule  or  investing  membrane  is  liable  to  considerable  change  in 
the  course  of  time.  The  most  common  is  that  of  an  increase  of  the 
thickness  of  the  membrane,  though  the  reverse  of  this  may  occur  under 
■exceptional  circumstances.  Calcification  and,  according  to  some  au- 
thorities, ossification  even  may  take  place  in  the  cyst-walls.  When 
calcification  takes  place  it  usually  forms  in  isolated  places  which  have 
no  connection  with  one  another,  though  they  occasionally  unite  and 
convert  the  entire  cyst-wall  into  a  firm,  calcareous  capsule.  Under 
such  circumstances  the  blood-supply  is  cut  ofif  by  the  occlusion  of  the 
vessels,  all  further  growth  of  the  tumor  is  arrested,  and  it  assumes  the 
position  of  a  foreign  substance  in  the  tissues. 

Destruction  of  the  cyst  membrane  may  also  take  place  from 
inflammatory  processes  arising  from  traumatic  injuries  or  inflamma- 
tion extending  from  surrounding  tissues.  An  injury  which  caused  an 
extravasation  of  blood  into  a  cyst  containing  serous  fluid  might  cause 
coagulation  of  the  entire  mass  and  result  in  its  obliteration.  Inflam- 
mation sometimes  leads  to  suppuration,  and  the  cyst  would  then  be 
converted  into  a  pus-sac,  which  would  destroy  the  epithelial  lining  and 
eventually  close  the  cavity  by  granulation.  Upon  this  fact  is  based  the 
treatment  often  adopted  by  surgeons  of  inducing  an  inflammation  by 
injecting  irritating  substances  like  iodin,  etc.,  into  the  cyst. 

Cysts  may  exist  throughout  a  lifetime  without  producing  any  ill 
effects,  yet  their  location  and  size  may  sometimes  become  a  menace  to 
life,  as,  for  instance,  when  occurring  in  the  neck,  they  may  seriously 
interfere  with  the  act  of  swallowing  and  with  respiration.  Cysts  of  the 
internal  organs,  when  of  large  size,  are  the  most  dangerous  to  life, 
usually  from  the  secondary  disturbances  which  they  induce  in  the 
organs  of  the  abdomen  and  thorax,  and  by  inflammatory  processes 
ending  in  suppuration  or  other  changes  in  the  cyst  itself;  or  rupture 
of  the  cyst  and  discharge  of  its  contents  into  the  peritoneal  cavity. 
Peritonitis  with  a  fatal  termination  has  often  resulted  from  the  latter 
condition,  on  account  of  the  highly  irritating  effect  often  possessed  by 
the  contents  of  such  cysts. 

Spontaneous  involution — a  shrinking  or  shriveling — of  the  cyst, 
whereby  the  capsule  becomes  hard,  dense,  and  rigid,  accompanied  by 
degeneration  of  the  papillary  growths  of  the  internal  surface,  has  been 
observed  in  the  ovarian  cysts  of  old  women. 

Cysts  of  the  Jaws  and  Teeth. — Cysts  of  the  jaws  which  are  found 
associated  with  the  teeth  may  be  classed  under  two  heads :  First, 
those  which  are  connected  with  the  roots  of  fully-developed  teeth ;  sec- 
ond, those  associated  with  malposed  teeth  or  those  of  abnormal  devel- 
opment. 


490  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

Single  cysts  in  the  form  of  accumulations  of  serum  or  degenerated 
pus  are  frequently  found  in  connection  with  the  roots  of  devitalized 
teeth  which,  from  septic  conditions,  have  been  the  subjects  of  inflam- 
matory processes,  usually  of  a  subacute  or  chronic  form,  and  which 
has  resulted  in  necrosis  or  erosion  of  these  apices.  These  cysts  are 
always  adherent  to  the  apex  of  the  root,  the  necrosed  or  eroded  por- 
tion being  inclosed  in  a  sac,  and  when  small  enough  to  pass  through 
the  alveolus  they  are  frequently  found  attached  to  the  apex  upon  the 
extraction  of  the  offending  tooth.  The  size  of  these  cysts  varies  con- 
siderably, and  they  are  found  associated  with  both  jaws,  but  they  never 
assume  the  character,  and  rarely  the  proportions,  of  the  ordinary  den- 
tigerous  or  tooth-bearing  cyst. 

Diagnosis. — This  class  of  cystic  tumor  is  always  found  located  be- 
neath the  periosteum,  hence  Magitot  denominates  them  periosteal  cysts. 
They  vary  in  size  from  that  of  a  pea  to  a  marble,  though  they  occa- 
sionally attain  much  larger  dimensions.  When  of  large  size,  they  cause 
extensive  resorption  of  the  bone,  considerable  swelling  and  deformity, 
and  if  located  in  the  superior  maxilla  they  may  simulate  empyema  of 
the  maxillary  sinus,  and  be  mistaken  for  that  disease,  while  in  excep- 
tional cases  the  cyst  may  occupy  the  antrum  and  give  rise  to  a  true 
empyema.  Heath  says  that  in  his  experience  large  cysts,  which  cause 
more  or  less  absorption  of  the  outer  wall  of  the  maxilla,  are  very  com- 
mon consequences  of  the  retention  of  diseased  teeth,  but  that  they 
seem  to  give  very  little  inconvenience  to  the  patients,  even  though 
they  may  be  so  large  as  to  produce  a  considerable  deformity  of  the  face. 

A  case  of  this  character  is  described  by  Heath  in  a  woman  forty 
years  of  age.  The  tumor  was  of  two  years'  standing,  and  situated 
immediately  above  the  incisor  teeth,  which  were  decayed  to  the  mar- 
gin of  the  gum.  The  maxillary  sinus  had  become  secondarily  involved, 
as  was  proved  by  passing  a  probe  through  the  incision  made  above  the 
incisor  teeth  for  the  evacuation  of  the  fluid.  A  case  somewhat  similar, 
which  came  under  the  observation  of  the  writer,  was  associated  with  a 
superior  lateral  incisor  and  involved  the  antrum.  Fischer,  as  quoted 
by  Heath,  reported  a  case  of  a  large  cyst  associated  with  the  root  of  a 
superior  posterior  molar,  in  which  he  had  the  opportunity  of  making  a 
post-mortem  examination.  After  removing  the  external  wall  of  the 
antrum,  the  cyst  was  found  to  be.  connected  with  the  pericementum  at 
the  apex  of  one  of  the  roots,  and  it  filled  the  whole  of  the  antrum  with- 
out being  connected  with  the  lining  mucous  membrane.  The  cyst  was 
composed  of  a  perfectly  closed  serous  sac,  with  a  smooth  inner  surface, 
and  contained  a  yellowish  serous  fluid. 

An  example  of  a  common  form  of  cysts  in  the  inferior  maxilla 
associated  with  devitalized  teeth  occurred  recently  in  the  private  prac- 
tice of  the  writer.     Miss  G.,  aged  thirty-five,  housekeeper,  had  a  pain- 


CYSTOMATA.  49I 

less  swelling-  of  the  right  side  of  the  lower  jaw  in  the  region  of  the 
bicuspid  teeth.  The  swelling  was  confined  to  the  outer  surface  of  the 
jaw,  and  extended  from  the  cuspid  tooth  to  the  first  molar;  the  gum 
over  the  tumor  was  purple  in  color  and  hard  to  the  touch,  except  at 
one  point  near  the  center,  where  there  was  evidence  of  fluctuation. 
Both  bicuspid  teeth  were  devitalized,  with  a  history  of  acute  abscess 
occurring  two  or  three  years  previously.  Puncture  of  the  tumor  re- 
vealed a  cyst  containing  a  thick,  straw-colored,  tenacious  fluid,  in 
which  were  found  glistening  flakes  of  cholesterin.  The  cyst  was  evac- 
uated and  explored,  when  it  was  discovered  that  the  roots  of  both  of 
the  bicuspids  were  involved  in  the  cyst,  and  that  they  were  consid- 
erably roughened  near  their  apices.  On  extracting  the  teeth,  it  w'as 
found  that  erosion  had  taken  place  at  the  apex  in  both  of  them. 

Another  case,  in  which  the  cyst  was  located  in  the  superior  max- 
illa, may  be  mentioned  as  a  rather  uncommon  type.  Mrs.  W.,  aged 
twenty-eight,  a  private  patient,  came  in  September,  1891,  with  a  large 
swelling  under  the  left  ala  of  the  nose,  involving  the  lip  and  side  of  the 
face.  The  swelling  was  painless,  and  had  been  of  rapid  growth,  the 
first  evidence  having  been  noticed  only  five  days  before.  On  raising 
the  lip,  the  gum  was  found  to  be  considerably  swollen,  very  red,  the 
disturbance  extending  from  the  cuspid  tooth  forward  to  the  median 
line.  Fluctuation  was  discernible  over  the  center  of  the  swelling. 
The  incisor  and  bicuspid  teeth  had  all  been  removed  some  years  before, 
on  account  of  extensive  caries  and  abscesses,  with  a  previous  history 
of  swelling  and  discharge  of  a  watery  fluid  at  frequent  intervals  in  the 
location  of  the  left  lateral  incisor,  twice  repeated  at  short  intervals  after 
the  extraction  of  the  teeth.  The  case  w^as  treated  by  incision  and  a  10 
per  cent,  solution  of  iodin  in  glycerol,  with  seemingly  a  speedy  cure. 
About  six  months  later  she  returned  with  a  recurrence  of  the  disease. 
This  time  a  careful  search  was  made  for  an  unerupted  tooth  or  a 
fragment  of  the  root  of  a  devitalized  tooth,  but  nothing  of  the  kind 
could  be  found.  The  cavity  w^as  then  thoroughly  curetted,  under  the 
belief  that  the  original  cyst-wall  had  not  been  destroyed  when  the  tooth 
had  been  extracted,  and  that  it  still  retained  the  power  of  exciting  a 
serous  exudation.  After  washing  out  the  cavity,  it  was  packed  from 
day  to  day  wdth  borated  gauze.  At  the  end  of  a  month  the  cavity  had 
closed  by  granulations,  and  no  further  inconvenience  had  occurred 
after  a  period  of  nearly  four  years. 

The  character  of  the  fluid  contained  in  cysts  associated  with  the 
diseased  roots  of  teeth  is  generally  a  dark  straws-colored,  gluey  liquid, 
often  containing  flakes  of  cholesterin.  Occasionally  it  is  thick  and 
ropy,  or  if  inflammation  has  been  recently  present,  the  contents  may 
be  purulent.  Tomes  suggests  that  cystic  disease  of  the  lower  jaw  may 
not  infrequently  be  associated  as  the  initial  cause  of  irritation  with  the 


492  SURGERY    OF   THE    FACE,    MOUTH,   AND    JAWS. 

roots  of  diseased  teeth.  When  the  disease  is  located  in  the  lower  jaw, 
it  is  generally  the  external  plate  of  the  alveolus  which  gives  way  under 
the  pressure  of  the  accumulating  fluid.  As  resorption  of  the  bone 
progresses,  crepitation  over  the  swelling  is  discernible,  and  if  sufficient 
time  elapses  the  bone  will  become  completely  resorbed,  while  fluctu- 
ation may  be  detected  through  the  membranous  covering  of  the  cyst. 
Spontaneous  rupture  of  the  tumor  sometimes  occurs,  but  this  does  not 
effect  a  cure,  for  as  soon  as  the  opening  in  the  cyst-wall  has  healed  the 
fluid  reaccumulates. 

The  history  of  this  form  of  cysts,  from  a  clinical  standpoint,  is  one 
of  painless  expansion  of  the  alveolus  and  surrounding  bone,  resorption 
of  the  bony  wall,  crepitation  under  pressure,  evidence  of  fluctuation, 
bluish  appearance  of  the  gum  immediately  overlying  the  cyst.  It  may 
be  located  in  the  alveolar  process  of  either  jaw,  but  most  commonly 
in  the  superior.  Wedl  is  of  the  opinion  that  these  growths  are  more 
commonly  found  anterior  to  the  bicuspid  teeth  than  posterior  to  them. 

Prognosis. — The  prognosis  is  one  of  recurrence,  unless  a  radical 
operation  is  performed.  Beyond  the  deformity  caused  by  the  swell- 
ing and  its  progressive  enlargement,  it  need  give  no  anxiety  as  to  its 
issue,  for  fatalities  from  this  cause  are  unheard-of  results. 

Treatment.- — The  treatment,  to  be  effective,  must  be  radical.  The 
diseased  tooth  must  be  first  extracted,  after  which  the  cyst  should  be 
opened  and  the  thin  external  wall  cut  away  with  scissors  or  the  bone- 
forceps,  and  the  cavity  thoroughly  curetted.  The  surgical  engine  and 
bone-cutting  burs  will  serve  an  admirable  purpose  in  this  class  of 
operations.  Curetting  the  cavity  without  removing  the  tooth,  or  re- 
moving the  tooth  without  curetting  the  cavity,  are  only  half-way  meas- 
ures, and  will  be  followed,  sooner  or  later,  by  a  recurrence  of  the  dis- 
ease. Simple  draining  of  the  cavity  is  likewise  a  futile  proceeding,  as 
are  all  attempts  to  evacuate  the  cyst  through  the  pulp-canal.  Failure  to 
cure  this  form  of  cyst  has  many  times  been  caused  by  lack  of  proper  ap- 
preciation of  these  simple  facts.  The  cavity,  after  it  has  been  curetted, 
should  be  dressed  by  packing  it  with  bichlorid  or  boric  acid  gauze, 
and  the  dressings  changed  once  or  twice  each  day  until  the  process  of 
healing  by  granulation  at  the  bottom  of  the  cavity  has  been  estab- 
lished, when  the  gauze  may  be  dispensed  with,  and  the  wound  kept 
clean  by  frequent  irrigation.  The  expanded  condition  of  the  bone  will 
gradually  disappear  as  the  healing  process  goes  on,  and  eventually  the 
deformity  will  entirely  pass  away. 


CHAPTER    XLIX. 

CYSTOMATA  (Continued). 
MULTILOCULAR    CySTS    OF   THE   JaWS. 

Definition. — A  muitilocular  cyst  is  a  congeries  of  small  cysts ;  a 
polycyst;  a  variety  of  cyst  having  many  cavities,  or  a  cyst  containing 
many  similar  smaller  cysts  attached  to  the  inner  wall  of  the  original 
cavity. 

True  cystoma  of  the  bone  is  an  exceedingly  rare  affection,  only  a 
very  few  cases  ever  having  been  reported.  The  most  interesting  one 
is  that  described  by  Engle,  which  occurred  in  a  woman  fifty-five  years 
of  age,  the  mother  of  six  healthy  children,  and  who  during  her  life 
gave  no  evidence  of  any  bone-affection.  Death  occurred  from  an 
acute  disease,  and  at  the  post-mortem  examination  it  was  discovered 
that  the  entire  skeleton  was  occupied  by  innumerable  cysts,  ranging 
in  size  from  a  pea  to  three  inches  in  diameter.  The  cyst-walls  were 
composed  of  a  layer  of  connective  tissue,  and  the  cysts  contained  in 
some  instances  a  clear,  in  others  a  bloody  serum. 

In  a  few  instances  smgle  cysts  of  considerable  size  have  been 
found  in  various  bones. 

Multiple  bone-cysts  resulting  from  "embryonic  inclusion  of  a 
matrix  of  epithelial  cells"  (Senn)  are  most  commonly  associated  with 
the  maxillary  bones.  Tumors  of  this  character  have  been  observed 
much  more  frequently  in  the  lower  than  in  the  upper  maxilla. 

Muitilocular  cysts  of  the  jaws,  also  known  as  proliferating  follicu- 
lar cystomata,  and  designated  by  Sutton  as  epithelial  odonfomes,  are  a 
type  of  cystomata  that  is  very  rare. 

Becker  recently  described  two  cases  which  were  seen  at  the  clinic 
at  Bonn,  and  he  has  been  able  to  find  but  sixteen  additional  cases  re- 
ported in  surgical  literature. 

Cysts  which  are  formed  from  the  beginning  with  separate  com- 
partments, or  which  are  produced  later  by  coalescence  wdth  other 
cysts,  or  by  proliferation  from  the  original  cyst,  are  termed  muitilocular 
cysts. 

Causes. — Muitilocular  cysts  of  the  jaws  are  in  most  cases  found 
associated  with  the  teeth  or  with  the  roots  of  teeth  which  have  lost 
their  crowns  from  caries,  and  which  have,  through  their  septic  influ- 

493 


494  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

ence,  been  the  cause  of  long-continued  irritation  and  inflammation. 
Occasionally  their  development  has  been  known  to  follow  an  injury 
to  the  jaw. 

The  etiology  of  this  affection  has  always  been  somewhat  obscure, 
and  even  at  the  present  time  there  still  remains  considerable  doubt  as 
to  the  real  cause  of  the  disease. 

Eve  maintained  that  multilocular  cysts  of  the  jaws  were  not  of 
dental  origin,  but  that  they  were  caused  by  an  ingrowth  or  inclusion 
of  the  epithelial  layer  of  the  gum,  and  that  they  followed  injury  and 
long-continued  irritation  from  diseased  teeth  and  inflammation.  He 
applied  the  term  multilocular  cystic  epithelial  tumor  to  these  growths. 

Senn  believes  that  they  are  developed  from  an  embryonic  inclu- 
sion (matrix)  of  epithelial  cells,  and  that  it  is  evident  that  misplaced 
dental  germs  are  not  the  cause  of  the  affection,  from  the  fact  that  the 
lower  jaw  is  most  frequently  the  seat  of  the  disease.  This  latter  fact 
may  find  its  explanation  in  the  greater  liability  of  the  lower  jaw,  from 
its  exposed  position,  to  receive  injuries,  while  the  upper,  from  its  loca- 
tion, is  comparatively  free  from  traumas. 

Sutton  thinks  that  multilocular  cysts  or  "epithelial  odontomes 
arise  probably  from  the  presence  of  persistent  portions  of  the  epi- 
thelium of  the  enamel-organs." 

The  origin  of  supernumerary  teeth  and  small,  malformed  teeth  or 
denticles  often  found  in  the  dentigerous  cysts  may  also  be  explained 
in  the  same  manner.  These  persistent  portions  of  the  epithelium  of 
the  enamel-organ  are  derived  from  the  epithelial  cord  of  the  tooth- 
germ,  which  has  been  cut  off  from  the  enamel-organ  by  the  closing 
of  the  dental  follicle.  After  the  cord  has  been  separated  from  the 
enamel-organ  by  this  process,  it  breaks  up  into  minute  globules  (Magi- 
tot),  which  are  absorbed;  but  if  for  any  reason  they  are  not  removed 
by  absorption,  these  globules  may  develop  into  supernumerary  teeth 
or  denticles,  or  they  may  induce  the  formation  of  multilocular  cysts, 
the  "epithelial  odontomes"  of  Sutton. 

Audry  is  of  the  opinion  that  multilocular  cysts  have  a  positive 
connection  with  the  enamel-organs;  he  also  succeeded  in  demon- 
strating the  epithelial  origin  of  these  growths.  Their  origin,  there- 
fore, would  invest  them  with  a  certain  degree  of  malignancy.  These 
observations  most  positively  confirm  the  first  researches  of  Falkson 
and  Malassez  as  to  the  origin  of  many  of  the  maxillary  tumors. 

Kruse  also  confirms  these  investigations,  and  considers  the  origin 
of  these  cysts  to  be  the  paradental  epithelial  debris  of  Malassez. 

Multilocular  cysts  are  sometimes  termed  proliferating  follicular 
cystoma,  from  the  nature  and  character  of  their  development,  which  is 
generally  thought  to  be  due  to  the  gland-like  arrangement  of  the 
"tumor  matrix"  and  the  proliferation  of  the  epithelial  cells.     The  can- 


CYSTOMATA.  495 

cellated  structure  of  the  bone  may  favor  the  multiple  character  and 
growth  of  this  variety  of  cyst,  by  the  rupture  or  absorption  of  the  thin 
septi  or  partition  walls  which  exist  between  the  vacuoles  or  loculi,  as 
the  cysts  grow^  and  the  fluid  increases  in  quantity. 

The  recent  anatomical  researches  of  Cryer  upon  the  inferior  max- 
illa also  favor  the  supposition  that  the  multilocular  character  of  these 
cysts  may  be  influenced  by  the  peculiarities  of  the  structure  in  which 
they  are  formed.  Cryer  has  demonstrated  the  inferior  dental  canal 
to  be  a  cribriform  structure;  that  an  abundant  communication  exists 
■between  the  vacuoles  or  loculi  of  the  cancellated  tissue  of  the  bone; 
that  the  alveoli  of  the  teeth  are  not  only  in  communication  with  the 
inferior  dental  canal,  but  with  the  loculi  of  the  cancellated  tissue  in  all 
■directions,  and  with  one  another  through  the  same  channels,  thus  fur- 
nishing, in  the  opinion  of  the  writer,  a  possible  explanation  of  the 
multilocular  character  of  those  cysts  of  the  lower  jaw  which  appear  to 
be  induced  by  the  irritation  of  diseased  teeth  and  traumatic  injuries. 

If,  therefore,  this  supposition  is  correct,  a  single  cyst  of  epithelial 
origin,  located  in  any  portion  of  the  alveolar  process,  the  ramus,  or 
body  of  the  maxilla,  might  readily  become  multiple  by  the  growth 
following  the  communicating  canals  and  occupying  the  loculi  of  the 
cancellated  tissue  in  its  immediate  neighborhood,  expansion  of  the 
loculi  taking  place  as  the  fluid  accumulated. 

Inflammation  alone,  according  to  Senn,  is  never  productive  of 
tumor-formations, — neoplasms, — but  that  inflammation  occurring  in 
the  immediate  neighborhood  of  a  tumor-matrix,  whether  of  pre-natal 
or  post-natal  origin,  causes  an  increase  or  augmentation  of  its  blood- 
supply,  which  arouses  the  embryonic  tissue  from  its  dormant  con- 
dition and  stimulates  it  to  active  cell-proliferation. 

Multilocular  cysts  of  the  jaws  (Fig.  214),  according  to  the  best 
authorities  upon  this  subject,  may  be  stated  to  be  caused  by  the  pres- 
ence within  the  jaws  of  embryonic  "inclusions"  or  "nests"  of  epithelial 
tissue — probably  derived  from  the  epithelial  cords  of  the  enamel- 
organs  during  the  development  of  the  teeth,  and  which  have  been  stim- 
ulated to  active  cell-proliferation  by  injuries  to  the  jaws,  inducing  an 
increase  in  their  blood-supply  through  inflammatory  conditions. 

The  causes,  therefore,  may  be  divided  into  Predisposing  or  Es- 
sential, and  Active  or  Exciting. 

The  predisposing  or  essential  cause  is  the  presence  within  the  jaw 
of  an  embryonic  epithelial  tumor-matrix. 

The  active  or  exciting  causes  are  inflammatory  conditions  and 
traumatic  injuries. 

The  disease  is  essentially  one  of  early  life,  the  majority  of  cases 
occurring  under  thirty  years  of  age.  Of  the  published  cases,  the 
youngest  was  an   infant  six  months  old,  the   cyst  being  congenital 


496 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


(Heath),  and  the  oldest  an  individual  of  seventy-five  years  of  age.  The 
development  of  these  cysts  usually  begins  in  childhood  or  at  puberty, 
and  they  are  of  slow  growth,  though  they  may  attain  a  very  consider- 
able size. 

One  case  described  by  Falkson  and  Bryk  reached  an  enormous 
size,  the  tumor  weighing  one  and  one-half  kilograms,  and  extending 
from  the  zygomatic  arch  to  the  sternum  (Senn). 

Fig.  214. 


MuLTiLOCULAR  Cyst  OF  THE  LowKR  Javv.     (Alter  Rogers.) 

They  are  located  most  frequently  in  the  region  of  the  bicuspid 
and  molar  teeth.  When  associated  with  the  upper  jaw  they  may 
rupture  into  the  antrum  of  Highmore. 

Pure  multilocular  cysts  are  commonly  considered  to  be  benign 
growths.  Degenerative  changes,  however,  are  liable  to  occur  in  those 
cysts  which  are  present  in  the  middle  and  later  periods  of  life,  the 
tendency  being  toward  sarcomatous  and  carcinomatous  transforma- 
tion. Authorities,  however,  differ  as  to  the  original  character  of 
malignant  multilocular  cysts  of  the  jaws.  Some  believe  them  to  be  a 
form  of  cystic  degeneration  of  sarcomatous  and  carcinomatous 
growths,  while  others  are  of  the  opinion  that  they  are  malignant 
degenerations  of  multiple  cysts  which  were  originally  benign. 


CVSTOMATA. 


497 


The  histologic  character  of  muhilocular  cyst  of  the  jaws  is  that 
of  an  epithehal  tumor,  and  consists  of  branching  and  anastomosing 
cokimns  of  epithehum,  portions  of  which  form  alveoH.  The  cells 
which  occupy  the  alveoli  vary ;  the  outer  layer  may  be  columnar,  while 
those  in  the  center  degenerate  and  give  rise  to  tissue  resembling  the 
stratum  intermedium  of  an  enamel-organ  (Sutton). 

Clinically  these  cysts  have  a  firm  capsule,  and  are  composed  of  a 
great  number  of  smaller  cysts  grouped  together  and  occupying  the 
cancellated  structure  of  the  bone.     The  individual  cysts  vary  in  shape 

Fig.  215. 


MuLTiLocuLAR  Cyst  OF  THE  LowER  jAw.     (After  Adams. 

A,  cuspid  ;  B,  second  molar:  C,  anterior  portion  of  dental  nerve;  D,  remains  of  the  base  of  the 

horizontal  ramus  excavated  on  its  upper  surface,  on  which  lay  the  tumor. 

and  size.  They  are  usually  of  the  dimensions  of  a  small  pea  to  that 
of  an  almond ;  exceptionally  they  are  much  larger.  These  cavities  are 
separated  by  thin  fibrous  or  bony  septa;  when  the  disease  is  of  long 
standing,  they  often  communicate  freely  with  each  other.  (Fig.  215.) 
The  contents  of  the  cysts  may  be  a  clear,  limpid,  mucoid  fluid;  in  other 
cases,  thick  and  almost  gelatinous,  and  of  brown  or  dark-brown  color. 
The  cvsts  in  the  portions  of  the  tumor  which  are  'growing  are 
lined  with  a  very  red,  pulpy,  vascular  membrane,  resembling  a  myeloid 
sarcoma. 

33 


498  SURGERY   OF   THE   FACE,   MOUTH,   AND  JAWS. 

Diagnosis  and  Symptoms. — The  cystic  character  of  these  tumors 
may  be  easily  ascertained  by  the  introduction  of  a  trocar  or  an  explor- 
ing needle,  but  the  multiple  character  of  the  cyst  cannot  be  positively 
demonstrated  except  by  an  incision,  or  by  the  extraction  of  the  teeth 
and  diseased  roots  involved  in  the  cyst,  which  may  sometimes  demon- 
strate its  character  by  the  escape  of  the  fluid. 

In  making  a  differential  diagnosis  this  form  of  cyst  must  not  be 
confounded  with  the  simple  cysts  wdiich  follow  suppurative  alveolar 
inflammation  of  devitalized  teeth,  nor  with  dentigerous  cysts,  nor  with 
cysto-adenoma,  cysto-sarcoma,  or  cysto-carcinoma.  The  character  of 
the  three  latter  forms  can  only  be  determined  by  microscopic  exam- 
ination. 

The  symptoms  are  the  presence  of  a  slow-growing,  painless 
tumor,  situated  in  the  region  of  the  bicuspid  or  molar  teeth,  usually  in 
the  lower  jaw,  but  occasionally  in  the  upper,  when  it  may  simulate 
mucous  engorgement,  or  cyst  of  the  antrum.  It  rarely  produces  ulcer- 
ation of  the  gums  or  infiltration  or  ulceration  of  the  external  tissues, 
but  when  such  conditions  have  occurred  they  have  always  been  asso- 
ciated wdth  a  malignant  degeneration  of  the  grow'th.  Heath  mentions 
three  cases  of  this  character. 

Prognosis. — Multilocular  cysts  of  the  jaws  are  comparatively  inno- 
cent growths ;  they  show  very  little  tendency  to  implicate  surrounding 
tissues,  to  involve  the  neighboring  lymphatic  glands,  or  to  cause  metas- 
tatic deposits.  When  thoroughly  removed  by  surgical  operation,  they 
rarely  recur.  Their  com.paratively  benign  character  is  doubtless  due 
to  the  bony  capsule  which  surrounds  them  (Heath),  their  somewhat 
scanty  vascular  supply,  and  the  especially  marked  tendency  possessed 
by  the  epithelial  cells  lining  the  cysts  to  undergo  colloid  degenera- 
tion. 

The  opposite  is  true  of  those  cysts  which  are  characterized  by  a 
sarcomatous  or  carcinomatous  degeneration  of  their  connective  or  epi- 
thelial tissues.  Under  such  conditions  there  is  a  distinct  tendency 
to  the  involvement  of  the  neighboring  lymphatics  and  surrounding 
tissues,  and  to  the  formation  of  metastatic  tumors. 

Treatment. — The  plan  of  treatment  usually  followed  in  cases  of 
multilocular  cysts  of  the  jaws  is  to  make  the  operation  through  the 
mouth,  in  order  that  unsightly  scars  may  be  avoided.  It  requires  a 
higher  degree  of  skill  and  a  larger  endowment  of  patience  upon  the 
part  of  the  surgeon  to  operate  successfully  through  the  mouth  in  these 
cases  than  it  does  to  lay  open  the  tissues  of  the  face  and  operate 
through  an  external  incision. 

When  operating  through  the  mouth,  the  jaws  should  be  separated 
as  widely  as  possible  with  a  suitable  mouth-gag  or  prop.  The  mucous 
membrane  over  the  cvst  is  then  freelv  divided,  and  dissected  from  the 


CYSTOMATA.  499 

external  plate  of  the  bone.     With  gouge  and  bone-forceps  the  external 
plate  of  bone  is  cut  away,  exposing  the  character  of  the  cyst. 

The  bony  and  fibrous  septa  are  now  brok-en  down  and  removed, 
and  the  inner  surface  of  the  cavity  thus  formed  thoroughly  curetted, 
any  sharp  projections  of  bone  being  smoothed  down.  After  irrigation, 
the  cavity  is  packed  with  antiseptic  gauze.  Granulations  soon  spring 
up  and  fill  the  cavity,  and  gradually  the  expansion  of  the  bone  and  the 
fullness  of  the  cheek  disappear,  and  no  scar  is  left  to  mar  the  symmetry 
of  the  face. 

When  the  character  of  the  cyst  is  of  a  nature  that  requires  the 
exsection  of  a  portion  of  the  body  of  the  jaw,  the  incisions  should  be 
made  in  such  locations  as  will  cause  the  least  deformity  by  reason  of 
the  cicatrix.  This  may  be  accomplished  by  a  vertical  incision  through 
the  lower  lip  upon  the  median  line,  carried  under  the  point  of  the  chin 
to  intercept  another  incision  made  from  the  angle  of  the  jaw,  following 
the  inner  border,  to  the  median  line.  The  soft  tissues  are  then  dis- 
sected from  the  bone  and  laid  back  upon  the  face.  This  exposes  the 
jaw  from  angle  to  symphysis.  A  tooth  is  extracted  in  front  of  and 
behind  the  tumor.  The  bone  is  then  cut  through  with  the  Hey's  saw, 
the  chain  saw,  or  a  circular  saw  revolved  by  the  surgical  engine,  and 
removed.  The  vessels  are  then  secured,  the  flap  stitched  into  position, 
and  antiseptic  dressings  applied. 

By  these  lines  of  incision  the  greater  part  of  the  cicatrix  is  hidden 
from  view,  which  is  a  matter  of  considerable  importance  to  the  un- 
fortunate patient. 

vSometimes,  by  cutting  away  the  diseased  bone  from  above,  it  may 
be  possible  to  leave  a  rim  of  healthy  bone  at  the  base  of  the  jaw;  this 
would  be  much  better  than  to  make  a  complete  exsection,  as  an  un- 
sightly deformity  often  results  from  the  latter  operation. 


CHAPTER   L. 
CYSTOMATA  (Continued). 

Dentigerous  Cysts. 

The  term  "Dentigerous  Cyst"  is  applied  by  most  writers  to  that 
form  of  cystic  tumor  associated  with  some  aberration  in  the  develop- 
ment of  the  teeth,  and  which  prevents  the  normal  process  of  their 
eruption.  Dentigerous  cysts  are  most  often  found  in  connection  with 
the  permanent  teeth,  occasionally  with  supernumerary  teeth,  but  very 
rarely  with  the  deciduous  teeth.  The  disease  may  occur  in  either  jaw, 
but  most  frequently  in  the  upper. 

The  most  frequent  aberrations  in  the  development  of  the  teeth 
are  malpositions  and  malformations,  and  these  conditions  seem  to  be 
those  which  most  often  act  as  causative  factors  in  the  production  of 
the  disease.  A  careful  review  of  the  literature  upon  the  subject,  sup- 
plemented by  personal  observation  in  an  extended  hospital  practice, 
confirms  the  opinion  that  in  nearly  every  case  the  aberrant  tooth  or 
teeth,  including  the  supernumerary  teeth,  found  in  a  dentigerous  cyst 
were  so  malposed  or  malformed  as  to  render  it  impossible  for  them  to 
emerge  from  their  crypts  and  assume  a  position  in  the  dental  arch. 

It  is  not  to  be  supposed,  however,  that  every  malposed  or  mal- 
formed tooth  which  remains  impacted  in  the  jaws  results  in  the  forma- 
tion of  a  cystic  tumor,  or  that  even  a  majority  of  them  so  result.  Indi- 
vidual teeth  frequently  fail  to  make  their  appearance  in  the  dental  arch, 
and  many  have  been  found  in  abnormal  positions,  or  abnormally  de- 
veloped, but  comparatively  few  ever  give  rise  to  serious  trouble.  The 
disease  may  therefore  be  considered  as  a  rare  affection. 

Sutton  applies  the  term  "Follicular  Odontomes"  to  the  tooth- 
bearing  or  dentigerous  cysts.  He  describes  them  as  follows:  "Follicu- 
lar odontomes  arise  commonly  in  connection  with  teeth  of  the  perma- 
nent set,  and  especially  with  the  molars.  Sometimes  these  tumors 
attain  large  dimensions  and  produce  great  deformity.  The  tumor 
consists  of  a  wall  of  varying  thickness,  which  represents  an  expanded 
tooth-follicle.  In  some  cases  it  is  thin  and  crepitant;  in  others  it  may 
be  one  centimeter  thick.  The  cavity  of  the  cyst  usually  contains  viscid 
fluid  and  a  crown  or  root  of  an  imperfectly  developed  tooth.  Occa- 
500 


CYSTOMATA.  5OI 

sionally  the  tooth  is  loose  in  the  foUicle,  sometimes  inverted,  and  often 
its  root  is  truncated;  exceptionally  the  tooth  is  absent.  The  walls  of 
the  cyst  always  contain  calcific  or  osseous  matter;  the  amount  varies 
considerably.     Follicular  odontomes  rarely  suppurate." 

Aberrant  teeth  which  pierce  the  gum  are  never  productive  of 
cystic  tumors,  though  it  occasionally  occurs  that  an  accumulation  of 
serous  fluid  will  be  found  surrounding  the  crown  of  an  advancing 
tooth,  but  this  is  immediately  discharged  upon  the  tooth  piercing  the 
gum,  and  does  not  again  reaccumulate.  Cysts  of  considerable  size 
sometimes  develop  in  this  way  when  the  temporary  teeth,  particularly 
the  molars,  are  retained  beyond  the  proper  time  for  them  to  be  exuvi- 
ated. Tomes  suggests  that  this  condition  may  occur  in  teeth  which 
are  deeply  imbedded  in  the  jaws,  the  fluid  collecting  between  the 
"enamel  and  the  tooth-capsule,  and  as  the  fluid  increases  in  amount 
the  bone  next  to  the  tooth  is  resorbed,  while  new  bone  is  formed  upon 
the  outside  of  the  jaw." 

Salter  says,  "When  a  tooth  is  impacted  in  the  jaw,  its  fang  is 
enclosed  in  a  bony  socket,  lined  by  periosteum,  as  in  ordinary  circum- 
stances, while  the  crown  of  the  tooth  is  free  in  a  little  bony  loculus 
lined  with  that  which  was  the  so-called  'enamel-pulp.'  This  structure 
is  clothed  with  a  sort  of  epithelium,  which  is  apt  to  assume  the  function 
of  secreting  fluid." 

Causes. — All  serous  exudations  are  the  result  of  some  form  of 
irritation,  usually  of  a  mild  chronic  type,  but  it  is  not  always  an  easy 
matter  to  determine  the  exact  character  of  the  irritation.  In  cysts 
connected  with  the  roots  of  devitalized  teeth,  the  irritant  is  easily 
determined,  but  in  exudations  not  so  associated  it  is  a  more  difficult 
matter.  It  would  seem,  however,  that  in  the  formation  of  dentigerous 
cysts  the  irritation  was  simply  mechanical,  identical  with  that  which 
accompanies  the  advancing  tooth  in  the  normal  process  of  eruption; 
but  on  account  of  the  malposition  or  the  malformation  of  the  offending 
tooth,  the  advancement  of  the  crown  is  impeded.  As  a  consequence  of 
this  impediment  to  its  progress,  irritation  of  the  surrounding  tissues  is 
produced,  resulting  in  a  low  inflammatory  process,  with  serous  exuda- 
tion, gradual  accumulation  of  the  fluids,  expansion  and  resorption  of 
the  bone,  accompanied  by  more  or  less  swelling  and  deformity. 

The  changes  which  take  place  in  the  contents  of  dentigerous  cysts 
are  in  no  way  different  from  those  which  are  found  in  connection  with 
serous  cysts  in  other  portions  of  the  body. 

The  dentigerous  or  tooth-bearing  cysts  are  not  always  confined  to 
the  jaw,  but  are  found  in  the  ovaries  of  the  human  female,  as  expres- 
sions of  a  modified  form  of  reproduction;  while  those  which  occur  in 
either  sex,  and  remote  from  the  location  of  the  reproductive  organs, 
must  be  classed  as  dermoid  cvsts. 


;02 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


Dermoid  Cysts  are  formed  as  a  result  of  an  infolding  of  the  epi- 
blast  or  hypoblast,  which  is  thereby  displaced  and  surrounded  by  the 
connective  tissue.  These  cells  thus  buried  in  the  connective  tissue 
continue  to  develop,  and  result  in  the  formation  of  an  epidermal  cyst 
(Fig.  216),  which  may  contain  any  or  all  of  those  tissues  which  are 
developed  from  the  epiblast  or  hypoblast,  namely:  the  skin,  hair,  nails, 
mucous  membrane,  the  teeth,  and  occasionally  muscle,  bone,  and  carti- 

FiG.  216. 


Dermoid  Cyst — Transverse  Section.    X  40. 


lage;  but  under  the  latter  circumstances  portions  of  the  mesoblast 
must  have  been  included  with  the  misplaced  portions  of  the  epiblast 
or  hypoblast. 

The  most  common  location  of  dermoid  cysts  is  in  the  generative 
organs,  especially  the  ovaries.  They  are  occasionally  found  in  other 
parts  of  the  body,  like  the  peritoneum,  the  neck,  the  sternum  (Fig. 
217),  the  region  of  the  orbit,  the  cheek  near  the  angle  of  the  mouth,  in 
the  median  line  of  the  chin,  on  the  side  of  the  nose,  and  in  the  median 
line  of  the  palate.  In  rare  cases,  fragments  of  bone,  flat  or  irregular, 
or  of  cartilage,  and  even  of  teeth,  are  found  beneath  the  cutaneous 


CYSTOMATA. 


503 


layer.  The  teeth  are  occasionally  free  within  the  cyst.  Teeth  are 
sometimes  found  in  connection  with  the  branchial  clefts  of  sheep,  oxen, 
and  horses.  Sutton  mentions  such  a  case  occurring  in  a  sheep  with 
persistent  fistula  of  the  second  branchial  cleft  and  surmounted  by  a 
prominent  cervical  auricle,  covered  upon  its  posterior  surface  by  a 
number  of  processes  resembling  the  buccal  papillae  of  sheep.  From 
this  auricle  grew  an  ill-formed  incisor  tooth,  mounted  upon  a  projec- 
tion of  bone  and  surrounded  by  mucous  membrane.  Professor  Sayer, 
of  the  Chicago  Veterinary  College,  recently  opened  a  dermoid  cyst 

Fig.  217. 


JT.BALC0M3.S=^=^S3=^ 


Dermoids  ovkr  the  Sternum  and  the  Left  Cornu  of  the  Hyoid  Bone,  in  Boy  aged 
Nineteen.    ^Bramann,  after  Sutton.) 

situated  in  the  temporal  region  of  a  horse  which  had  been  discharging 
an  offensive  secretion  for  several  months,  and  found  lying  upon  the 
bottom  of  the  cyst  a  well-developed  incisor  tooth. 

Dermoid  cysts  are  classed  among  the  congenital  tumors.  They 
are  found  most  commonly  in  young  persons,  though  they  have  been 
discovered  in  the  aged.  Their  growth  is  usually  very  slow  and  en- 
tirely painless. 

The  simple  forms  are  those  found  in  detached  or  seqiiestered  por- 
tions of  the  surface  epithelium,  where  during  embryonic  life  union 
takes  place  between  skin-covered  surfaces;  as,  for  instance,  upon  the 


504  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

median  line  of  the  body,  and  along  the  lines  of  coalescence  of  the  vari- 
ous embryonic  fissures  of  the  face  and  neck.  The  more  complicated 
forms  are  those  occurring  in  the  ovaries  and  in  connection  with 
mucous  surfaces.  Sutton  is  authority  for  the  statement  that  teeth  are 
never  found  in  those  dermoids  which  arise  in  connection  with  the  sur- 
face epithelium.  They  are,  however,  of  fairly  frequent  occurrence  in 
ovarian  dermoids,  and  also  in  rectal  and  post-rectal  tumors  of  this 
character.  The  writer  is  of  the  opinion  that  teeth  are  never  found  in 
dermoids  other  than  those  associated  with  the  generative  organs  or  the 
mucous  membrane.  The  former  class  result  from  an  abortive  effort  of 
the  function  of  reproduction;  the  latter  from  an  accident  of  develop- 
ment. The  teeth  are  formed  from  the  layers  of  the  mucous  membrane, 
the  hypoblast,  and  not,  as  often  stated,  from  the  epiblast.  The  same 
accidents  of  displacement  which  occur  in  the  epiblast  may,  under  the 
same  circumstances,  happen  to  the  hypoblast,  which  may  result  in  the 
formation  of  tumors  containing  any  or  all  of  the  tissues  which  are 
developed  from  the  hypoblast,  viz:  the  mucous  membrane,  with  its 
glandular  appendages,  etc.,  and  the  teeth.  These  accidents  of  devel- 
opment explain,  in  a  measure,  the  occasional  presence  of  teeth  in  the 
cervical  region  of  the  human  subject,  which  have  been  usually  classed 
as  erratic  third  molars. 

One  of  the  most  remarkable  cases  of  dentigerous  cysts  ever  noted 
is  that  described  by  F.  E.  Glaswald,  of  Pomerania,  in  1844,  and  quoted 
at  some  length  by  Salter.  The  history  of  the  case,  as  gathered  from 
Salter,  is  briefly  as  follows:  The  patient  was  a  healthy  girl  of  about 
eight  years  of  age  when  the  disease  first  showed  itself.  The  earlier 
symptoms  were  frequent  attacks  of  violent  pulsating  pain  in  the  right 
superior  maxilla,  involving  the  alveoli  and  the  teeth,  which  were  re- 
lieved by  fomentations  and  general  treatment.  A  year  later  the  symp- 
toms recurred,  accompanied  by  redness,  swelling,  and  fever.  After 
the  subsidence  of  the  active  symptoms  of  inflammation,  a  permanent 
enlargement  of  the  cheek  remained,  but  no  definite  tumor.  These 
attacks  were  frequently  repeated  during  the  following  two  years,  with 
a  constantly  increasing  fullness  of  the  cheek,  so  that  at  the  age  of  ten 
years  the  right  side  of  the  face  presented  a  large,  tumor-like  promi- 
nence. An  unusually  violent  attack  occiirred  at  this  time,  accom- 
panied by  inflammation  of  the  antrum  and  elevation  of  temperature, 
which  was  supposed  to  have  been  the  result  of  exposure  to  cold.  At 
the  end  of  five  days  the  sinus  opened  spontaneously  in  the  zygomatic 
region,  with  profuse  discharge  of  pus.  The  case  was  then  treated  in 
hospital  by  Dr.  Warnekros,  who  extracted  the  molar  teeth,  dilated  the 
external  aperture,  and  established  a  counter-opening  in  the  canine 
fossa.  This  resulted  in  diminishing  the  size  of  the  tumor.  Five  years 
later  the  left  cheek  was  attacked  in  precisely  the  same  manner,  and 


CVSTOMATA.  5^5 

continued  until  the  patient  was  nineteen  years  of  age.     The  right  side 
also,  at  the  same  time,  began  slowly  to  enlarge.     A  second  operation 
was  performed  at  this  time  by  Dr.  Kneip  by  opening  the  left  antrum, 
which  was  followed  by  the  discharge  of  a  large  quantity  of  fetid  pus. 
No  necrosed  bone  could  be  discovered.     The  patient  had  now  become 
very  much  disfigured,  the  antra  remaining  permanently  dilated  and 
the  cheeks  very  prominent.     A  third  operation  was  made  by  Professor 
Baum,  who  opened  both  antra  and  removed  a  portion  of  the  external 
walls.     Upon  the  left  side  an  opening  w^as  made  just  below  the  canine 
fossa,  which  was  followed  by  the  discharge  of  about  an  ounce  of  clear 
yellow,  fetid  serum,  and  upon  exploring  the  antrum  with  the  finger 
the  crown  of  a  molar  tooth  was  discovered  firmly  attached  to  the 
bone;  it  was  extracted  with  difficulty.     The  right  antrum  was  opened 
in  about  the  same  location,  and  a  cuspid  tooth  was  found  loosely  at- 
tached to  the  wall  and  easily  removed.    This  sinus  contained  fetid  pus. 
After  several  months,  there  was  little  change  in  the  size  of  the  tumor. 
Another  notable  case  of  the  disease  occurring  in  the  inferior 
maxilla  published  by  Mr.  Fearn,  of  the  Derby  Infirmary,  in  the  British 
Medical  Journal,  1864,  and  quoted  by  Heath,  is  also  of  especial  m- 
terest.     The  patient,  a  girl  thirteen  years  of  age,  had  a  large,  hard 
tumor,  which  occupied  the  whole  of  the  horizontal  ramus  of  the  left 
side,  and  which  had  been  growing  for  six  months.     The  surface  of  the 
tumor  showed  a  fetid  discharge,  but  there  was  no  discoverable  open- 
ing.    The  right  side  of  the  maxilla  was  also  somewhat  enlarged,  and 
the  teeth  irregular.     The  teeth  of  the  right  side  had  been  extracted 
with  the  exception  of  a  temporary  molar  and  the  second  permanent 
molar.     The  left  half  of  the  jaw  was  removed  from  the  symphysis  to 
the  articulation,  under  the  mistaken  diagnosis  of  a  solid  tumor.     The 
tumor  proved  to  be  a  bone-cyst,  formed  by  the  expansion  of  the  two 
plates  of  the  maxilla,  and  which  extended  for  some  distance  to  the 
right  of  the  symphysis.      The  cyst  was  lined  with  a  thick  vascular 
membrane,  and  at  the  bottom  a  cuspid  tooth  was  found  projecting 
from  the  wall,  and  which  was  evidently  the  cause  of  the  disease.    (Figs. 

218,  219.) 

Another  somewhat  similar  case  was  published  by  Dr.  Forget. 
The  patient  was  a  woman  thirty  years  of  age,  having  a  tumor  of  the 
right  side  of  the  inferior  maxilla  the  size  of  a  hen's  egg,  wdiich  ex- 
tended from  the  lateral  incisor  to  the  base  of  the  coronoid  process,  and 
had  been  slowly  growing  for  ten  years.  M.  Lisfranc  removed  the 
right  half  of  the  jaw,  and  upon  examination  of  the  tumor  it  was  found 
to^be  a  dentigerous  cyst,  with  the  third  molar  in  an  inverted  position, 
the  roots  located  in  the  base  of  the  coronoid  process,  and  the  crown 
projecting  downward  and  into  the  cyst.     (Fig.  220.) 

The  following  cases  from  the  practice  of  the  writer  are  of  sufificient 
interest  in  this  connection  to  warrant  their  appearance  in  these  pages: 


5o6 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


Miss  Anna  T,,  aged  sixteen  years,  light  complexion,  well  nour- 
ished, and  in  general  good  health,  was  referred  to  the  writer  by  Pro- 
fessor John  Van  Duyn,  of  Syracuse  University,  November  21,  1881, 
for  a  tumor  of  the  left  inferior  maxilla  the  size  of  a  hen's  egg  in  the 


Fig.  218. 


Dentigerous  Cyst.     (After  Heath.) 
a,  unerupted  cuspid  tooth. 


Fig.  219. 


Dentigerous  Cyst— Lateral  View.     (After  Heath.) 
a,  mental  foramen. 

region  of  the  molar  teeth,  and  apparently  involving  the  entire  structure 
of  the  left  half  of  the  jaw,  the  swelling  extending  upward  along  the 
ramus  toward  the  maxillary  articulation. 

The  first  molar  tooth  had  been  extracted  about  three  months 


CYSTOMATA. 


507 


previously,  under  the  mistaken  diagnosis  of  an  alveolar  abscess.  The 
second  molar  was  in  place,  but  very  loose;  the  third  molar  had  not  yet 
made  its  appearance.  The  swelling  of  the  jaw,  which  was  first  noticed 
fifteen  months  before,  had  been  of  slow  growth  and  painless,  except  on 
taking  cold,  when  the  pain  was  only  slight  and  of  short  duration. 
Pressure  over  the  tumor  produced  indentation  of  the  tissues,  with 
parchment-like  crepitation,  but  there  was  no  discoloration  of  the  exter- 
nal integument.  There  was  slight  tenderness  of  the  parts,  and  some 
difficulty  in  opening  and  closing  the  mouth,  though  mastication  could 
still  be  performed  upon  the  right  side. 

With  the  tumor  of  the  jaw  there  existed  a  goitre  of  small  size. 

Fig.  220. 


Dentigerous  Cyst  of  Lower  Jaw.     (After  For-get.) 
a,  third  molar  inverted  ;  b,  internal  wall ;  c^  inferior  dental  canal. 

The  contents  of  the  tumor  were  found  to  be  a  straw-colored 
serum.  This,  with  the  fact  of  the  location  of  the  tumor,  led  to  the 
diagnosis  of  dentigerous  cyst,  dependent,  in  all  probability,  upon  the 
unerupted  third  molar. 

The  patient  afterward  sought  other  advice,  and  the  second  molar 
was  extracted,  "followed  by  the  escape  of  a  thick,  tenacious  fluid  re- 
sembling the  albumen  of  an  t^g."  The  patient  returned  a  month 
later  for  operation.  In  the  mean  time  the  cyst  had  increased  to  about 
double  its  former  size.  The  tumor  was  laid  open  within  the  mouth, 
along  the  alveolar  border,  from  the  angle  to  the  second  bicuspid  tooth, 
and  the  fluid  contents  of  the  cyst  removed,  which  consisted  of  a  thick, 
dark-yellow  serum,  slightly  mixed  with  pus,  in  quantity  at  least  four 
ounces.     On  exploration  with  the  finger  introduced  into  the  opening, 


508  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

several  sharp  spiculae  of  bone  could  be  felt  upon  the  sides  and  bottom 
of  the  cyst  cavity, — probably  the  remains  of  the  alveoli  of  the  ex- 
tracted teeth, — while  in  the  posterior  part  of  the  cavity,  well  up  toward 
the  sigmoid  notch  and  at  the  base  of  the  condyloid  process,  the  crown 
of  the  third  molar  could  be  distinctly  outlined.  This  was  easily  dis- 
lodged with  an  elevator,  and  extracted  by  the  aid  of  the  bullet  forceps. 
On  further  examination  it  was  found  that  the  condyloid  process 
and  the  posterior  part  of  the  ramus  were  separated  from  the  coronoid 
process  and  the  anterior  portion,  and  detached  from  the  surrounding 
tissues,  the  periosteum  having  been  entirely  separated  from  this  por- 
tion of  the  bone;  it  was  therefore  removed  through  the  cyst  cavity  and 
incision  within  the  mouth. 

Fig.  221. 

."^ 

/    i 


l-"--> 


The  extracted  condyle  showed  evidences  of  necrosis,  and  upon 
further  examination  it  was  discovered  that  the  cyst  had  extended  so 
far  backward  as  nearly  to  sever  the  condyle  from  the  coronoid  process 
and  body  of  the  jaw,  while  the  force  applied  to  dislodge  the  tooth, 
though  very  moderate,  no  doubt  completed  the  separation.  The  con- 
dyle was  also  separated  from  its  fibro-cartilage.  On  placing  the  tooth 
in  the  crypt  in  which  it  was  developed  on  the  portion  of  the  jaw  re- 
moved (Fig.  221),  it  was  found  to  have  occupied  an  inverted  posi- 
tion, the  grinding  surface  of  the  crown  directed  downward,  forward, 
and  outward.  The  tooth  was  incomplete  in  development,  the  crown 
only  being  formed. 

The  patient  made  a  good  recovery,  with  reformation  of  lost  bone 
and  perfect  mobility  of  the  joint. 


CYSTOMATA.  5^9 

Mrs.  Hulda  A.,  aged  twenty-nine  years,  farmer's  wife,  came  for 
consultation  on  March  8,  1882,  for  a  tumor  of  the  right  side  of  the 
superior  maxilla  situated  in  the  region  of  the  bicuspid  and  first  molar 
teeth,  occupying  the  alveolar  ridge,  and  about  the  size  of  a  pigeon's 
egg,  firm  and  unyielding  to  the  touch. 

Six  months  previously  she  had  the  second  bicuspid  of  the  right 
side  extracted,  which  was  badly  decayed.  The  first  bicuspid  and  first 
molar  had  been  lost  for  some  years;  had  not  noticed  the  enlargement 
of  the  jaw  until  some  weeks  after  the  second  bicuspid  had  been  ex- 
tracted. The  formation  of  the  tumor  had  been  slow  and  painless,  and 
she  only  sought  advice  on  account  of  its  becoming  troublesome  from 
its  size  and  the  disfigurement  of  the  face. 

The  tumor  was  punctured  with  a  heavy  exploring  needle,  which 
revealed  the  presence  of  a  clear,  straw-colored,  thick,  ropy  fluid.  An 
opening  was  made  through  the  entire  length  of  the  swelling,  and  the 
fluid  discharged.     The  sac  was  then  explored  with  the  finger,  and  at 

Fig.  222. 


First  Temporary  Molar  (enlarged). 
I,  pulp-chamber  opened  and  enlarged  by  resorption. 

the  upper  part  a  jagged  substance  was  felt,  which  was  at  first  thought 
to  be  a  piece  of  denuded  bone;  but  on  removing  it  with  the  forceps, 
after  considerable  exertion,  it  was  found  to  be  a  first  deciduous  molar 
of  perfect  form,  except  for  the  loss  of  a  portion  of  the  root,  evidently 
from  resorption,  and  placed  in  the  jaw  in  an  inverted  position,  the 
roots  pointing  downward.  Resorption  had  been  most  active  upon  the 
distal  aspect  of  the  roots,  and  had  penetrated  the  pulp-chamber,  which 
was  exceedingly  large.  The  tooth  was  somewhat  discolored,  and  had 
the  appearance  of  having  been  bathed  in  a  yellowish-brown  staining 
fluid  for  a  considerable  period.     (Fig.  222.) 

Mr.  B.,  aged  twenty-four  years,  a  medical  student,  consulted  the 
writer,  during  the  winter  of  1886,  for  a  tumor  in  the  region  of  the  max- 
illary tuberosity  of  the  right  side,  behind  the  third  molar,  but  which 
v.^as  only  partiall}^  erupted. 

The  gum-tissue  was  considerably  swollen,  and  the  jaw  much  en- 
larged and  broadened  at  this  point.  There  was  a  slight  fullness  under 
the  malar  bone,  but  no  crepitation  or  fluctuation  could  be  detected, 
though  severe  pain  was  at  times  experienced,  and  the  tissues  were 
painful  to  touch.     A  diagnosis  of  impacted  or  difficult  eruption  of  the 


510 


SURGERY    OF    THE    FACE,    MOUTH,    AND   JAWS. 


third  molar  being  made,  the  tooth  was  cut  down  upon  and  removed, 
the  removal  being  followed  by  a  discharge  of  a  watery  fluid  mixed 
with  pus,  and  of  offensive  odor.  On  probing  the  alveolus  from  which 
the  tooth  had  just  been  extracted,  enamel  could  be  felt,  and  upon  en- 
larging the  alveolus  with  the  bone-forceps  five  small  supernumerary 
teeth  were  removed,  of  imperfect  form,  resembling  the  canines  of  a 
kitten. 

Several  cases  of  this  character  are  to  be  found  on  record.  Fig.  223 
shows  a  group  of  dwarfed  and  malformed  teeth  removed  from  a  cyst 
by  Tomes,  and  Fig.  224  shows  three  teeth  removed  from  a  cyst  by 
Cryer. 

Fig.  22T,. 


Dwarfed  and  Malformed  Teeth  from  a  Dentigerous  Cyst  of  the  Right  Side  of  the 
Upper  Jaw.    (After  John  and  Charles  S.  Tomes.) 


Fig.  224. 


Right  Upper  Incisor  and  Cuspid  found  in  a  Cystic  Cavity.    (After  M.  H.  Cryer.) 


Diagnosis  and  Symptoms. — The  question  of  age  is  one  that 
should  be  considered  in  making  the  diagnosis.  The  disease  has  oc- 
curred as  late  as  the  sixtieth  year,  but  the  great  majority  of  cases  are 
under  thirty  years.     The  disease  is  essentially  one  of  early  life. 

The  symptoms  of  a  dentigerous  cyst  are  principally  local  in  their 
manifestations,  and  consist  of  expansion  of  the  maxillary  bone  in  some 
definite  locality,  with  a  corresponding  deformity  of  the  features,  a  sense 
of  weight  and  tension,  sometimes  pain  and  general  constitutional  dis- 
turbance. 

Pressure  over  the  tumor  produces  a  peculiar  parchment-like  crepi- 


CYSTOMATA.  5^^ 

tation,  and  when  the  bone  is  sufficiently  thinned,  fluctuation  may  be 
detected. 

The  most  important  diagnostic  sign  is  the  absence  of  one  or  more 
teeth  which  should  have  made  their  appearance  in  the  mouth,  and 
which  have  not  been  extracted.  The  teeth  corresponding  with  the  age 
of  the  patient,  however,  may  all  be  in  position  or  accounted  for,  and 
yet  the  fact  that  a  supernumerary  tooth  may  be  the  cause  of  the  disease 
must  not  be  overlooked.  Impacted  temporary  teeth  are  very  rarely 
met  with,  and  the  formation  of  a  dentigerous  cyst  from  this  cause  is 
even  more  rare. 

Fluid  may  be  detected  by  the  exploring  needle,  the  trocar,  or  by 
aspiration.  This  should  never  be  neglected  in  a  doubtful  case,  in  order 
that  a  needlessly  severe  operation  may  be  avoided.  The  presence  of 
a  serous  fluid  should  be  additional  evidence  in  favor  of  the  diagnosis 
of  a  tooth-bearing  cyst.  The  discovery  of  a  tooth  in  the  cyst  may 
often  be  made  by  the  introduction  of  a  probe  passed  through  an  inci- 
sion made  in  the  cyst-wall. 

The  character  of  the  fluid  in  dentigerous  cysts  is  usually  a  clear, 
yellowish,  albuminous,  viscid,  ropy  serum;  occasionally  it  becomes 
puriform  when  the  cyst  has  been  the  seat  of  a  suppurative  inflam- 
mation or  other  changes. 

The  subsequent  changes  which  may  take  place  in  dentigerous 
cysts  are  the  same  as  occur  in  cysts  in  other  locations  of  the  body,  and 
may  lead  to  a  mistaken  diagnosis.  The  character  of  their  contents  is 
subject  to  considerable  deviation.  A  trauma  may  induce  a  hemor- 
rhage into  the  cavity,  and  the  contents  of  the  cyst  be  so  mixed  with 
blood  as  to  be  mistaken  for  an  extravasation  cyst;  or  colloid  degen- 
eration may  convert  the  fluid  to  a  honey-like  liquid;  or  calcification 
may  occur,  in  floating  particles  of  coagulated  fibrin  or  blood-clots, 
while  the  cyst  membrane  may  be  so  filled  with  calcareous  deposits  as 
to  lead  to  the  supposition  that  the  tumor  was  an  osseous  growth. 
Heath  describes  a  case  of  this  character.  The  cyst  was  located  in  the 
right  antrum,  but  had  no  attachment  to  the  walls  of  the  sinus  except 
to  its  floor.  Complete  calcification  had  taken  place,  and  upon  open- 
ing the  cyst  a  supernumerary  tooth  was  found  loose  in  the  cavity,  but 
which  evidently  had  been  attached  originally  to  its  base. 

Differential  Diagnosis.— Cysts  of  the  maxillary  bones  may  be 
confounded  with  other  affections  of  this  locality  in  which  swelling  or 
enlargement  of  the  bone  is  a  prominent  symptom. 

Dentigerous  cysts  are  commonly  located  in  the  body  of  the  bone, 
and  usually  attain  a  considerable  size,  while  cysts  associated  with  the 
roots  of  devitalized  teeth  are  usually  confined  to  the  alveolar  process, 
are  of  much  smaller  size,  and  do  not  cause  expansion  of  both  plates 
of  the  bone. 


512  SURGERY    OF    THE    FACE,    MOUTH,    AND   JAWS. 

The  fibromata,  chondromata,  sarcomata,  myxomata,  abscesses, 
and  empyema  of  the  antrum  all  cause  swelling  and  enlargement  of  the 
•parts,  and  consequently  errors  have  been  made  in  diagnosis  which 
have  occasionally  led  to  serious  consequences.  An  abscess,  however, 
can  be  distinguished  by  its  rapid  course  and  constitutional  symptoms, 
and  an  empyema  usually  by  the  more  symmetrical  enlargement  of  the 
facial  surface  of  the  jaw.  Tumors  occupying  the  maxillary  sinus  some- 
times produce  the  same  even  enlargement,  but  an  exploring  needle 
passed  into  the  tumor  will  usually  demonstrate  its  character  in  a  gen- 
eral way.  If  the  contents  are  fluid,  the  needle  will  meet  with  little 
resistance,  while  the  liquid  will  escape  from  the  puncture  made  by  it. 
On  the  other  hand,  a  solid  tumor  will  offer  considerable  resistance  to 
the  passage  of  the  needle;  the  more  dense  the  tumor,  the  greater  will 
be  the  resistance. 

Prognosis. — A  dentigerous  cyst  is  usually  a  curable  disease,  and 
the  deformity  occasioned  by  the  expansion  of  the  bone  is  one  which 
gradually  passes  away  after  the  removal  of  the  exciting  cause.  Occa- 
sionally, however,  the  deformity  may  persist,  even  after  the  disease 
has  been  cured.  Cysts  of  the  jaws  are  not  themselves  liable  to  cause 
serious  results,  but  secondary  complications  may  arise,  like  suppura- 
tion followed  by  septic  fever,  in  which  there  would  be  more  or  fess 
danger  of  a  fatal  termination. 

AVhen  properly  treated,  the  issue  of  these  cases  is  almost  uni- 
versally satisfactory.  They  are  very  rarely  associated  with  other 
bone-disease. 

Treatment. — The  requirements  of  any  treatment,  to  be  effective, 
must  comprise  not  only  the  evacuation  of  the  cyst,  but  the  removal 
of  the  exciting  cause  of  the  disease.  This  may  require,  in  some  cases, 
an  extended  operation,  but  with  skill  it  may  be  confined  to  the  mouth. 
The  writer  cannot  conceive  of  a  condition  of  cyst  of  the  jaws  that  may 
not  be  .better  and  more  successfully  treated  through  the  mouth  than  by 
incisions  through  the  external  tissues  of  the  face,  except  where  exsec- 
tion  of  the  body  of  the  jaw  is  required. 

The  operation  usually  practiced  is  to  open  the  cyst  freely,  and  then 
for  cosmetic  reasons  to  cut  away,  with  bone-forceps,  gouge,  or  burs, 
the  external  plate  of  the  expanded  bone.  Some  operators  prefer  to 
crush  in  the  external  wall  instead  of  cutting  it  away;  but  in  many  cases 
this  is  not  necessary,  as  sooner  or  later  resorption  will  restore  the 
normal  outline  of  the  jaw.  After  the  fluid  has  been  evacuated,  a  care- 
ful search  must  be  made  for  the  offending  tooth,  but  such  effort  does 
not  always  prove  successful.  It  is  certain,  however,  that  it  is  some- 
where in  communication  with  the  cyst,  either  covered  by  the  cyst 
membrane  or  imbedded  in  a  crypt  and  communicating  with  the  cyst 
through  a  small  opening. 


CVSTOMATA.  513 

In  large  cysts  with  thin  external  wall  the  expanded  bone  may  be 
crushed  down,  and  afterward  the  cyst  cavity  packed  with  gauze  and 
permitted  to  close  by  granulation. 

In  some  instances  there  will  be  a  persistent  reaccumulation  of 
serous  fluid.  Under  such  circumstances  it  may  become  necessary 
either  to  inject  the  cyst  with  astringent  and  stimulating  fluids,  or  to 
reopen  it,  and,  by  means  of  a  curette,  thoroughly  destroy  the  investing 
membrane. 


34 


CHAPTER   LI. 

CARCINOMATA. 

Definition. — Carcinoma  (from  the  Greek  Kap/ctVos,  a  crab,  and  o/xa, 
a  tumor). 

(Carcinoma  is  a  malignant  neoplasm  of  the  epiblastic  group  of 
tumors,  and  is  formed  by  an  active  proliferation  of  epithelial  cells  from 
a  matrix  of  embryonic  cells,  usually  of  congenital  origin.) 

Carcinoma  is  of  all  diseases  the  one  upon  which  the  surgeon 
looks  with  the  greatest  dread  and  apprehension.  It  is  a  disease  which 
for  centuries  has  baffled  the  most  earnest  search  for  its  cause,  and  ren- 
dered the  highest  degree  of  surgical  skill  of  little  benefit  as  a  curative 
measure,  though  some  little  progress  has  been  made  during  the  last 
two  or  three  decades  in  certain  lines  of  investigation  which  have  had 
for  their  object  the  tracing  of  the  disease  to  its  histogenetic  origin. 
More  recently — during  the  last  decade — great  interest  has  been 
awakened  in  the  etiology  of  carcinoma,  from  the  investigations  of  the 
bacteriologists  who  have  endeavored  to  prove  the  bacterial  origin  of 
the  disease.  Up  to  the  present  time,  however,  the  true  cause  of  car- 
cinoma has  not  been  discovered,  but  there  would  seem  to  be  reason 
to  hope  that  eventually  such  cause  will  be  found,  and  in  all  probability 
through  the  researches  of  the  bacteriologist. 

Investigations  looking  to  the  discovery  of  therapeutic  measures 
for  the  constitutional  treatment  of  carcinoma  have  likewise  engaged 
the  attention  of  many  of  the  best  minds  in  the  profession,  but  so  far  no 
remedy  has  been  found  which  has  the  slightest  permanent  value  as  a 
curative  agent. 

It  is  to  be  hoped,  however,  that  with  the  discovery  of  the  real 
cause  of  carcinoma  will  come  the  therapeutic  remedy  which  will  not 
only  successfully  combat  its  ravages,  but  will  also  furnish  the  means 
of  prevention. 

Origin. — Carcinoma  belongs  to  the  epithelial  group  of  tumors. 
The  generally  accepted  teaching  in  relation  to  the  origin  of  all  forms 
of  carcinoma  is  the  theory  of  Cohnheim,  viz:  That  the  disease  arises 
from  a  misplaced  matrix  of  embryonic  epithelial  cells  of  congenital  origin. 

Senn  and  others  believe  that  such  tumors  may  also  arise  from  a 
proliferation  of  embryonic  cells  of  post-natal  origin,  as  the  result  of  vari- 
514 


CARCINOMATA.  515 

ous  forms  of  injury  or  disease  which  may  produce  a  displacement  of 
the  epithehal  cells  into  tissues  where  they  do  not  normally  belong, 
thus  forming-  a  tumor-matrix  from  which  a  carcinoma  may  ultimately 
develop. 

Carcinoma  may  be  described  as  an  atypical  proliferation  of  epi- 
thelial cells  (Waldeyer).  (The  term  atypical  means  irregular,  not  con- 
formable to  the  type;  the  opposite  of  typical.)  Primary  carcinomatous 
growths  are  usually  found  associated  with  tissues  like  the  skin,  mucous 
membrane,,  or  glandular  structures,  and  particularly  in  those  glands 
having  ducts  which  communicate  with  the  external  surfaces  of  the 
body,  or  with  canals  having  such  communications. 

A  typical  epithelial  tumor  is  one  in  which  the  epithelial  elements 
remain  within  their  normal  boundaries;  do  not  break  through  the 
memhrana  propria  and  encroach  upon  the  connective  tissue.  The  base- 
ment membrane,  or  membrana  propria,  forms  the  dividing  line  or 
boundary  between  the  epithelial  cells  and  the  connective  tissue.  A 
true  adenoma  is  an  epithelial  tumor  of  this  type.  An  atypical  epithelial 
tumor  is  one  in  which  the  new  epithelial  cells  break  through  the 
physiologic  boundaries  and  extend  into  the  connective  tissue.  Car- 
cinoma is  an  epithelial  tumor  of  this  type.  In  other  words,  a  typical 
epithelial  tumor  is  formed  by  a  proliferation  of  epithelial  cells  within 
epithelial  tissue  and  in  a  normal  location,  while  an  atypical  epithelial 
tumor  is  formed  by  the  proliferation  of  epithelial  cells  within  a  tissue 
of  a  different  type,  and  in  a  location  where  they  do  not  properly  be- 
long. 

In  the  consideration  of  primary  carcinoma  in  unusual  locations, 
the  possibility  of  a  post-natal  origin  from  traumatisms  or  disease  which 
may  cause  a  displacement  of  embryonic  epithelial  cells  must  not  be 
overlooked. 

Varieties  and  Structure. — Histologically,  all  carcinomatous  tumors, 
of  whatever  form,  are  composed  of  epithelial  cells,  grouped  and 
arranged  in  a  characteristic  order,  in  an  alveolated  connective- 
tissue  stroma.  The  epithelial  cells  have  their  origin  in  a  pre-existing 
tumor-matrix,  while  the  stroma  is  derived  from  the  connective  tissue 
in  which  the  essential  matrix  has  been  implanted,  or  into  which  the 
proliferating  epithelial  cells  afterward  migrate.  The  proliferation  or 
multiplication  of  the  epithelial  cells  (carcinoma-cells)  of  these  growths 
is  by  karyokinesis  (Filbry).  The  embryonic  character  of  the  epithelial 
cells  is  maintained  throughout  their  entire  development,  which  condi- 
tion of  the  cells  marks  the  difference  between  the  benign  and  the 
malignant  types  of  epithelial  tumors. 

The  chief  differences  in  structure  \vhich  exist  between  the  various 
forms  of  carcinoma — epithelioma,  scirrhus,  encephaloid,  colloid,  and 
glandular  carcinoma — arise  from  their  location,  the  type  of  epithelial 


5i6 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


cells  of  which  they  are  composed,  or  the  form  and  degree  of  the  degen- 
erative changes  which  take  place  in  them.  Histologically,  carcinoma 
may  be  divided  into  three  forms:  the  squamous-celled,  the  cylindrical- 
celled,  and  the  glandular. 

Epithelioma  is  a  term  which  has  been  used  to  designate  carcin- 
oma of  the  skin  and  mucous  membrane,  regardless  of  whether  it  orig- 
inated in  the  rete  Malpighii  or  the  glandular  appendages  of  these 
tissues. 

Fig.  225. 


Cells  from  an  Epithelial  Carcinoma  of  the  Bladder.    X  250.     (After  Perls.) 

The  carcinoma-cells  indicate  their  epithelial  origin  by  their  pe- 
culiar form.  (Fig.  225.)  These  cells  are  large,  of  varying  sizes  and 
shapes,  containing  one  or  more  round  or  oval  nuclei  with  large, 
glistening  nucleoli  (Warren). 

The  stroma  is  composed  of  fibrous  tissue,  more  or  less  infiltrated 
with  small,  round  cells,  and  traversed  by  blood-vessels.  The  stroma 
may  be  abundant  or  scanty.  In  the  slow-growing,  hard  forms  of  car- 
cinoma the  stroma  is  abundant,  while  in  the  rapid-growing,  soft  va- 
riety it  is  scanty. 

The  blood-vessels  and  lymphatics  are  located  in  the  stroma, 
through  which  they  ramify  in  all  directions.    The  blood-vessels,  unlike 


CARCINOMATA. 


517 


those  in  sarcoma,  arc  normal  in  thickness  and  construction,  and  are 
confined  in  their  ramifications  to  the  stroma,  while  in  sarcoma  they  pass 
among-  the  cells.  The  blood-supply  is  always  increased  in  the  devel- 
opment of  carcinoma.  The  general  plan  of  the  histologic  structure 
of  all  forms  of  carcinoma  is  the  same,  but  each  variety  has  some  pe- 
culiar characteristic  in  the  form  and  arrangement  of  its  cells  which 
distinguishes  it  from  the  others.     These  may  be  briefly  described  as 

follows : 

Fig.  226. 


A  Cell-Nest  from  a  Cancer  of  the  Lip.    X  300-    (After  J.  D.  Hamilton.) 
a  stroma  of  the  alveolus  in  which  the  cell-nest  is  contained;  b,  small  germinal  cells  of  the  peri- 
phery ;  c,  prickle-cells ;  rf,  compressed  squamous  cells  ;  e,  degenerated  cells  in  the  center. 

Squamous-Celled  Carcinoma.— This  variety  is  located  in  the 
skin,  the  squamous  epithelial  cells  of  which  are  arranged  in  concentric 
layers  within  the  alveoli,  forming  what  are  known  as  "cell-nests/'  "can- 
cer-nests," or  "epithelial  pearis."  The  oldest  cells  are  found  in  ^the 
center  of' the  nest,  the  young  cells  at  the  periphery.  (Fig.  226.)  Car- 
cinoma grows  or  extends  by  the  migration  of  the  cancer-cells— which 
possess  an  amoeboid  movement— into  the  connective-tissue  spaces. 
Each  cell  possesses  the  power  of  multiplication,  and  thus  new  colonies 
are  formed.  With  the  growth  of  the  colony  there  is  a  separation  of 
the  connective-tissue  fibers,  resulting  in  the  formation  of  an  alveolus. 
This  process  goes  on  indefinitely,  with  greater  or  less  rapidity,  accord- 
ing to  the  resistive  power  of  the  tissues.  This^form  of  the  disease  is 
usually  described  under  the  term  "epithelioma." 


5i8 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


Cylindrical- Celled  Carcinoma. — This  form  of  the  disease  is  found 
in  the  mucous  membrane,  the  cohmmar  or  cyHndrical  cells  of  which 
are  arranged  in  the  form  of  tubules,  simulating  the  structure  of  tubular 

Fig.  227. 


Carcinoma  of  the  Rectum.    A  Single  Tubule,  showing  Multiplication  of  Cells  in  its 

Lining.    X  170.     (After  Senn.) 

a,  Space  due  to  shrinkage  in  hardening. 


Fig.  228. 


Epithelioma — Cylindrical— of  Stomach.    X  200. 

glands.  This  tubular  structure  corresponds  to  the  cell-nests  of  the 
squamous-celled  variety  of  the  disease.  The  arrangement  of  the  col- 
umnar cells  does  not  follow  the  typical  form  of  a  tubular  gland,  but 


CARCINOMATA. 


519 


forms  an  irregular  lining  of  the  crypts.     In  this  respect  it  differs  from 
adenoma,  in  which  the  typical  form  of  the  tubules  is  present.     (Figs. 

227,  228.) 

Infiltration  of  the  stroma  with  leucocytes  and  young  carcmoma- 
cells  is  a  common  condition.  This  indicates  its  tendency  to  rapid 
growth  and  malignancy.  Mucoid  and  colloid  degeneration  of  the 
cylindrical  cells  and  stroma  frequently  attends  this  form  of  carcmoma. 

Fig.  229. 


More  degen- 
erate growth 
and  medul- 
lary in  char- 
acter. 


Typical  stro- 
ma and  cells. 
Scirrhous 
type. 


Carcinoma-Scirrhus-from  Tongue  of  Cow.    X  40- 

Glandular  Carcinoma.— The  location  of  this  form  of  carcinoma 
is  in  the  conglomerate  glands,  like  the  mamm^,  kidneys,  liver,  tes- 
ticles, etc.,  the  acini  of  which  present  the  same  alveolated  structure  of 
the  stroma  as  is  found  in  the  squamous-celled  variety.  In  glandular 
carcinoma  the  acini  of  the  gland  constitute  the  alveoli,  while  the  con- 
nective tissue  between  them  forms  the  stroma.  The  size  of  the  alveoli 
and  the  amount  of  the  stroma  are  governed  by  the  character  of  the 
growth  and  the  degree  of  malignancy. 


520  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

In  the  hard,  slow-growing  varieties  the  alveoH  are  small  and  the 
stroma  abundant,  while  in  the  rapid-growing,  soft  varieties  the  stroma 
is  scanty  and  the  alveoli  large.  It  may  therefore  be  stated  as  a  well- 
established  fact  that  in  proportion  as  the  alveoli  are  large  and  the 
amount  of  connective  tissue  which  makes  up  the  stroma  or  reticulum 
is  small,  so  will  be  the  degree  of  malignancy  of  the  disease. 

The  term  scirrhus  cancer  has  been  applied  to  the  hard,  slow- 
growing  variety  of  carcinoma.  This  form  of  the  disease  is  found  most 
frequently  in  the  mammary  glands;  it  is  also  occasionally  found  in  the 
stomach,  testis,  ovary,  pancreas,  and  kidney.     (Fig.  229.) 

To  the  soft,  rapidly-growing  variety  the  term  encephaloid  cancer 
has  been  applied,  from  its  resemblance  to  brain-tissue.  It  is  most  fre- 
quently found  in  the  mucous  membrane,  the  liver,  testis,  bladder, 
kidney,  ovary,  fundus  oculi,  and  occasionally  in  the  breast. 

The  epithelial  cells  in  both  these  varieties  are  spheroidal.  This 
is  due  to  the  fact  that  the  epithelium  in  which  the  neoplasm  originates 
is  spheroidal  rather  than  columnar. 

Retrograde  changes  in  cancerous  growths  frequently  take  place 
in  the  cells  and  stroma  at  a  very  early  period  in  their  history. 

Fatty,  mucoid,  and  colloid  degenerations  are  prone  to  occur  in 
the  cells  of  glandular  carcinoma.  Calcification  is  occasionally  seen  in 
cancers  of  feeble  growth.  To  these  degenerative  changes  is  due  the 
confusion  which  has  arisen  in  the  classification  of  carcinomatous 
growths. 

A  very  rare  and  peculiar  form  of  carcinoma  is  a  variety  known 
as  Cylindroma  carcinomatodcs.  This  variety  of  the  disease  is  a  species 
of  colloid  degeneration  occurring  primarily  in  glandular  structures. 
Ziegler  states  that  he  had  observed  but  one  case,  and  this  was  asso- 
ciated with  the  lachrymal  gland.  Histologically  it  is  "characterized 
by  the  formation  of  homogeneous  spherules  within  the  cell-nests. 
These  spherules  are  generally  regarded  as  masses  of  colloid  substance 
which  press  asunder  the  other  cells  of  the  group.  If  a  considerable 
number  of  these  spherules  form  within  the  same  loculus,  the  cells  may 
be  compressed  into  slender  trabeculse,  and  so  come  to  form  a  kind  of 
anastomosing  net-work."  (Ziegler.)  Fig.  230  shows  a  primary 
growth  of  this  character  which  was  located  in  the  stomach,  most  of 
which  was  in  a  state  of  colloid  degeneration,  and  Figs.  231  and  232 
metastatic  growths  in  the  liver  and  the  brain  from  the  same  case. 

Infection  and  Dissemination. — All  true  carcinomatous  growths 
are  clinically  of  a  highly  malignant  character. 

Progressive  infection  of  the  immediately  surrounding  tissue,  of 
the  neighboring  anatomic  structures,  and  general  dissemination  of  the 
cancer-cells  through  the  lymphatic  and  circulatory  apparatuses  mark? 
the  malignant  character  of  carcinoma.     These  conditions  are  made 


CARCINOMATA. 
Fig.  230. 


521 


Cylindroma  Carcinomatodes — Primary  Growth — of  the  Stomach.    X  75.     (A.) 
a,  stroma  with  round-celled  infiltration  ;  b,  carcinoma  cells  ;  c,  alveoli  or  acini. 

Fig.  231. 


Cylindroma  Carcinomatodes— Metastatic— of  the  Liver,  from  a  Primary  Growth  in  the 

Stomach.    X  75-    (B.) 
a,  fatty  degeneration  of  liver-cells  ;  b,  carcinoma. 


522 


SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 


manifest  in  the  progressive  growth  of  the  tumor,  in  the  involvement  of 
the  neighboring  healthy  tissues,  regardless  of  the  character  of  these 
structures,  and  in  the  formation  of  secondary  carcinoma  in  distant 
organs  and  tissues  which  have  no  anatomic  relationship  to  the  tissues 
which  are  the  seat  of  the  primary  disease. 

The  local  extension  of  carcinoma  to  -all  tissues  and  organs,  irre- 
spective of  their  structure,  is  the  most  marked  feature  in  the  pathology 
and  the  clinical  historv  of  the  disease,  and  may  be  considered  almost 
a  pathognomonic  sign. 

Fig.  232. 


CvLixDROMA  Carcinomatodes— Metastatic— OF  the  Brain,  from  a  Primary  Growth  in  the 

Stomach.    (C.) 
a,  degeneration  fcolloid)  ;  b,  brain  stroma. 

The  use  of  the  term  infection,  as  applied  to  tumors  of  malignant 
type,  rests  upon  the  power  possessed  by  the  '"cancer-cells"  to  leave  the 
primary  tumor  and  to  wander  into  the  surrounding  healthy  tissue,  thus 
establishing  new  centers  of  growth ;  or  by  being  transplanted  through 
the  lymphatic  channels  or  by  the  blood-current,  to  reproduce  the  dis- 
ease in  contiguous  regions  or  in  distant  parts  of  the  body  {Senn). 

This  power  to  migrate  and  multiply  in  the  mesoblastic  tissues 
which  is  possessed  by  the  cancer-cells  does  not  explain  the  malignancy 
of  such  growths. 

Waldeyer  and  Thiersch  both  observed  and  described  the  power  of 
epithelial  cells  to  penetrate  into  tissues  of  apparently  healthy  char- 
acter, but  "normal  epithelial  cells  do  not  possess  the  same  power  of 


CARCINOMATA, 


523 


multiplication  in  the  mesoblastic  tissues  as  do  the  epithelial  cells  of 
carcinoma"  (Scnn).  It  may  therefore  be  stated  with  some  degree  of 
certainty  that  some  change,  at  present  not  understood,  takes  place  in 
the  epithelial  cells,  which  increases  to  a  marked  degree  their  power 
of  multiplication,  while  at  the  same  time  the  resistive  powers  of  the 
tissues  in  which  they  are  implanted  are  more  or  less  lowered.  These 
changes  may  be  due  to  the  influence  of  a  specific  micro-organism 
which  has  gained  access  to  the  tissues,  but  proof  upon  this  point  has 
not  been  demonstrated.  If  this  is  a  correct  view  of  the  conditions,  it 
may  be  readily  understood  how  the  growth  and  progress  of  carcinoma 
on  the  one  hand  may  be  rapid,  while  upon  the  other  it  is  slow,  these 
conditions  depending  upon  the  rapidity  of  cell-proliferation  and  the 
physiologic  resistance  of  the  tissues  in  which  the  disease  is  found. 

Malignancy,  however,  depends  not  only  upon  the  progressive 
growth  of  the  neoplasm,  but  upon  the  infection  of  other  tissues  in  its 
neighborhood  and  its  general  dissemination  throughout  the  body, 
causing  numerous  other  centers  of  cancerous  growth. 

Local  infection  takes  place  by  the  migration  of  young  carcinoma- 
tous cells  from  the  periphery  of  the  tumor  into  the  connective-tissue 
spaces.  The  progressive  extension  of  the  growth  is  always  in  the 
direction  of  the  pre-existing  connective-tissue  spaces,  consequently  it 
spreads  most  rapidly  and  attains  its  largest  dimensions  wdien  located 
in  regions  supplying  an  abundance  of  loose  connective  tissue. 

Regional  infection  is  the  result  of  the  transplantation  of  patho- 
genic material  from  the  seat  of  the  primary  tumor  to  the  lymphatic 
glands  of  the  region,  through  the  lymph-channels.  It  is  a  well-estab- 
lished clinical  fact  that  the  lymphatics  in  the  immediate  neighborhood 
of  a  primary  carcinoma  sooner  or  later  become  affected,  and  that  the 
secondary  growth  is  in  all  respects  similar  to  the  primary  tumor.  The 
pathogenic  material  carried  to  the  lymphatic  glands  is  generally  be- 
lieved to  be  young  carcinoma-cells  which  have  found  their  way  into 
the  tymph-channels  and  have  been  carried  by  the  lymph-stream  and 
deposited  in  the  glands.  The  glands,  acting  as  filters,  arrest  the  fur- 
ther progress  of  the  cancer-cells,  and  new  foci  are  established  for  the 
development  of  the  disease  in  these  structures.     (Fig.  233.) 

Paget  was  of  the  opinion  that  even  minute  portions  of  the  proto- 
plasm of  the  carcinoma-cells  were  as  effective  in  reproducing  the  dis- 
ease as  the  whole  cells.  Gussenbauer  believed  secondary  carcinoma  to 
be  due  to  the  transplantation  of  minute  infective  corpuscular  elements 
from  the  primary  tumor  to  the  lymphatic  glands  through  the  lymph- 
channels. 

General  infection  is  expressed  in  the  development  of  carcinoma- 
tous tumors  in  tissues  and  organs  in  distant  locations  of  the  body 
which  have  no  anatomic  relationship  with  that  portion  of  the  body  in 


524 


SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 


which  the  primary  tumor  is  located.  The  dissemination  of  the  in- 
fective material  is  brought  about  through  its  entrance  into  the  general 
circulation.  This  may  be  accomplished  either  by  direct  entrance  to 
the  blood-current  through  the  perforation  or  injury  of  a  vein-wall,  or 
by  indirect  entrance  through  the  lymphatic  system.  Such  material 
is  capable  of  passing  through  the  pulmonary  circulation,  and  of  being 
carried  to  remote  portions  of  the  body,  where  it  may  become  arrested 
in  the  capillaries,  forming  an  embolus  from  which  a  carcinomatous 
growth  may  develop.  This  process  of  dissemination  is  termed  meta- 
stasis, and  the  tumors  developed  from  such  process  metastatic  tumors. 

Fig.  233. 


Secondary  Carcinoma  of  Lymphatic  Gland.    :<  480,  reduced  one-third.     (After  Senn.) 

a, a,  groups  of  carcinoma-cells;    b,  lymphoid  corpuscles  and  reticulum.    Each  one  of  the  epithelial 

nests  is  the  product  of  tissue-proliferation  of  a  single  carcinoma  cell. 

The  size  of  the  carcinomatous  emboli  will  in  large  measure  deter- 
mine the  location  of  the  metastatic  tumor  (Senn).  Large  emboli  may 
become  lodged  in  the  pulmonary  artery,  while  the  minute  ones  pass 
the  pulmonary  capillaries  and  enter  the  arterial  circulation,  where  they 
may  become  attached  to  the  walls  of  the  vessels  or  pass  on  until  they 
form  emboli  in  vessels  too  small  to  admit  them  to  pass.  In  this  way 
only  the  presence  of  metastatic  carcinoma  in  locations  which  have  no 
anatomic  connections  with  the  seat  of  the  primary  disease  can  be  ex- 
plained. 

The  organs  which  are  most  frequently  the  seat  of  metastatic  car- 
cinoma are  the  lungs  and  the  liver.  The  bone  is  occasionally  the  seat 
of  secondary  carcinoma,  and  Wagner  has  collected  fifteen  cases  of 
this  form  of  the  affection  in  the  choroid.  Metastatic  carcinoma  of  the 
lungs  sometimes  becomes  a  supply  station  from  which  the  entire  body 
may  become  infected  with  "miliarv  carcinosis."     This  form  of  the  dis- 


CARCINOMATA. 


525 


ease  closely  resembles  miliary  tuberculosis  in  its  appearance,  and  is  a 

rapidly  fatal  form  of  the  disease.     Fi.s^s.  234,  235,  236.  237.  2^9^,  show 

Fig.  234. 


M.AMMARV  Gland  of  Cat  (A  ) 
Carcinoma— Scirrhus— Primary  growth.    Metastatic  nodules  appeared  in  the  kidneys,  intestines, 
lungs,  heart,  and  spleen. 

Fig.  2^S- 


Kidneys  of  Cat  (B  ) 
a,  metastatic  carcinoma  nodules. 

primary  scirrhus  carcinoma  of  the  mammary  gland  of  a  cat  and  meta- 
static infection  ("miliary  carcinosis'")  of  the  lungs,  the  spleen,  the  kid- 
nevs,  heart,  stomach,  ovaries,  uterus,  and  intestines. 


526 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


Prevalence. — Climate  and  habit  of  life,  sex  and  age,  all  seem  to 
exert  a  more  or  less  marked  influence  over  the  prevalence  of  cancerous 
disease. 

Carcinoma  is  said  to  be  less  prevalent  in  the  torrid  than  in  the 
temperate  zones,  and  most  frequent  in  damp,  low-lying  districts. 
Negroes  are  thought  to  be  less  liable  to  the  disease  than  the  white  race. 

The  aboriginal  races  are  singularly  exempt  from  the  disease. 
Few  cases  have  been  reported  among  the  North  American  Indians. 

Fig.  236. 


Stomach  and  Intestines  of  Cat  (C). 
Metastatic  carcinoma  nodules. 

The  disease  seems  to  be  peculiarly  an  affection  of  the  higher  civiliza- 
tion, and  influenced  to  a  considerable  degree  by  climatic  conditions. 
Some  idea  of  the  prevalence  of  the  disease  may  be  gained  from  the 
statement  that  there  are  about  thirty  thousand  persons  at  all  times  in 
England  suffering  from  cancer.  The  registrar-general's  report  for 
England  and  Wales  (1896)  shows  an  increased  mortality  from  cancer 
which  is  out  of  all  proportion  to  the  increase  in  the  population. 
W.  Roger  Williams,  in  the  Lancet  for  1898,  shows  that  in  1840  the 
deaths  from  cancer  were  2786,  the  proportion  to  the  population  being 
I  in  5646  and  i  in  129  of  the  total  mortality  for  that  year,  or  177  in 
each  million  living  persons.     In  1896  the  recorded  deaths  from  cancer 


CARCINOMATA. 


527 


numbered  23,521,  or  i  in  1306  of  the  total  poi)ulation.  and  i  in  22  of  the 
total  mortality,  or  763  per  million  living  persons.  According  to  these 
figures  it  will  he  seen  that  ilio  mortality  from  cancer  has  increased  in 
England  and  \\'ales  four  and  one-half  times  in  a  little  more  than  half  a 
century.  These  are  startling  facts  and  should  arrest  the  attention  of 
physicians  and  sanitarians  everywhere  and  stimulate  investigation  into 
the  causes  of  this  unprecedented  increase  of  the  disease.  The  census  of 
1880  of  the  United  States  gives  the  deaths  during  that  year  from  cancer 
as  13.068,  of  which  4875  were  males  and  8193  were  females. 


Fig.  237. 


Fig.  238. 


Nodules. 


Heart  and  Lungs  of  Cat  (D). 
Metastatic  carcinoma  nodules. 


Spleen  of  Cat  (E). 
Metastatic  carcinoma  nodules. 


Billings  states  that  cancer  is  especially  prevalent  in  the  New  Eng- 
land States  and  on  the  Southern  Pacific  coast;  that  it  is  prevalent  in 
New  York,  Pennsylvania,  Ohio,  and  in  the  interior  of  Michigan  and 
the  southern  part  of  Wisconsin.  It  is  least  prevalent  in  the  Mississippi 
Valley  and  in  the  South,  while  the  proportions  are  generally  lower  in 
the  coast  regions  than  in  the  interior. 

Park  claims  that  the  cancer  mortality  is  greater  in  Western  New 
York  and  the  adjoining-  region  than  in  any  other  part  of  the  country 
except  a  limited  section  of  California. 

Sex. — Carcinoma  in  general  is  much  more  common  in  women 
than  in  men,  and  sex  seems  to  exert  a  strong  influence  in  determining 


528 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


the  location  of  the  disease.  Carcinoma  of  the  lip  and  of  the  pyloric 
orifice  of  the  stomach  are  common  in  men,  but  rare  in  women,  while, 
on  the  other  hand,  carcinoma  of  the  breast  and  of  the  genitals  are 
frequently  seen  in  women  and  very  seldom  in  men. 

Age. — Carcinomatous  growths  are  most  prevalent  in  persons  who 
have  reached  or  passed  middle  life.  They  are  extremely  rare  in  early 
life  and  very  common  in  advanced  age.  Senile  tissue  changes  seem  to 
be  particularly  favorable  to  the  development  of  the  disease,  while  the 
consequent  lowering  of  the  powers  of  vital  resistance  and  recuperation 
incident  to  advanced  age  places  the  tissues  in  a  condition  most  favor- 
able for  the  rapid  growth  of  a  tumor-matrix  and  the  dissemination  of 
the  carcinoma-cells  through  the  system. 

Paget  has  published  an  interesting  table  showing  the  influence 
of  age  and  the  general  increasing  mortality  of  cancer  with  each  suc- 
ceeding decade  from  birth  to  eighty  years  of  age : 

facet's  table. 

Under   lO  years 5      per  cent. 

Between  10  and  20  years 6.g 


20  ' 

'  30   " 

30  ' 

'  40   " 

40  • 

'  50   " 

so  ' 

'  60   " 

60  ' 

'  70   " 

70  ' 

'  80   " 

100 

113 

107 

126 

Walshe  has  also  shown  from  statistics  that  the  death  rate  from 
cancer  "steadily  increases  with  each  decade  until  the  eightieth  year." 

When  the  disease  occurs  in  young  persons  it  is  an  evidence  that 
the  epithelial  cells  composing  the  tumor-matrix  are  unusually  en- 
dowed with  the  power  of  cell-proliferation,  or  that  the  individual  is 
peculiarly  susceptible  to  cancer  formation;  or  that  the  tissues  contain- 
ing the  misplaced  epithelial  cells  have  sustained  an  injury  of  some 
form  which  has  lowered  their  vitality  or  physiologic  resistance,  and 
placed  them  in  a  condition  to  favor  the  growth  and  multiplication  of 
carcinomatous  cells. 


CHAPTER   LII. 

CARCINOMATA  (Continued). 


Causes.— Until  some  better  theory  is  advanced  to  account  for  the 
origin  of  carcinomatous  growths,  we  must  hold  fast  to  the  modified 
theory  of  Cohnheim,  that  all  such  neoplasms  arise  from  the  presence  in 
the  mesoblastic  tissues  of  a  matrix  of  embr}^onic  epithelial  cells  of  pre- 
natal or  post-natal  origin.  The  essential  factor  in  the  production  of  all 
forms  of  epithelial  neoplasms,  benign  and  malignant,  is  the  presence  of 
misplaced  epithelial  cells  in  tissues  of  mesoblastic  origin,  but  the  influ- 
ences or  agencies  which  impart  innocency  or  malignancy  to  growths 
which  in  their  incipiency  are  histologically  identical,— for  all  carcin- 
omas have  a  benign  stage,— have  not  yet  been  discovered. 

The  etiology  of  the  disease,  therefore,  presupposes  the  existence  of 
an  essential  cause,  with  a  predisposition  or  tendency  to  the  develop- 
ment of  carcinomatous  growths,  and  active  or  exciting  agencies  which 
stimulate  the  essential  cause  into  active  cell-proliferation.  The  essen- 
tial cause,  if  not  excited  to  activity,  may  remain  in  a  dormant  condition 
for  years,  or  never  give  evidence  of  its  presence  within  the  tissues. 

The 'essential  cause  of  all  carcinomatous  growths  is  the  presence 
within  the  mesoblastic  tissues  of  embryonic  epithelial  cells  of  congenital 
or  post-natal  origin.  "In  the  absence  of  such  an  essential  histologic 
basis,  no  exciting  cause  or  combination  of  exciting  causes  will  result  in 
the  production  of  a  carcinoma."     (Senn.) 

The  congenital  origin  of  the  tumor-matrix  is  by  far  the  most  fre- 
quent The  tumors  which  arise  from  post-natal  influences,  if  the  inves- 
tigations of  Cohnheim,  Billroth,  and  others,  upon  the  cause  of  carci- 
noma are  correct,  amounts  to  about  20  per  cent.  Boll's  statistics 
place 'it  at  14  per  cent.  Wolff's  yielded  only  12  per  cent.  The  post- 
natal influences  which  give  origin  to  the  formation  of  carcmoma  are 
traumatisms  which  bury  fragments  of  embryonic  epithelial  tissues  m 
structures  of  mesoblastic  origin;  or  portions  of  these  tissues  which  are 
buried  in  the  process  of  healing  of  wounds,  or  the  repair  of  lesions  of 
inflammatory  origin.  Such  a  tumor-matrix  acts  as  a  foreign  sub- 
stance inducing  vascular  excitement  in  its  immediate  neighborhood 
with  the  proliferation  of  embryonic  epithelial  cells,  which,  faihng  to 
reach  maturity,  become  carcinomatous  tissue. 

35  529 


530  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

Cohnheim,  Leopold,  and  Zahn  found  by  experiments  that  mature 
tissue,  transplanted  into  the  anterior  chamber  of  the  eye  and  the  peri- 
toneal cavity  of  rabbits,  was  invariably  removed  by  absorption  in  a  very 
short  time;  while,  on  the  other  hand,  embryonic  tissue  which  had  been 
taken  from  animals  before  they  were  born,  and  transplanted  into  living 
animals,  not  only  retained  its  vitality,  but  continued  to  grow  to  an  ex- 
tent which  was  very  remarkable.  Fetal  cartilage  grafted  in  this  man- 
ner increased  in  bulk  from  two  to  three  hundred  times  its  original  size. 

Predisposing  Causes. — The  most  prominent  predisposing  cause  of 
carcinomatous  growths  is  diminished  vital  or  physiologic  resistance 
(Thiersch),  either  of  the  entire  organism  or  of  the  particular  location 
surrounding  the  tumor-matrix.  The  agencies  which  produce  these  con- 
ditions have  not  been  demonstrated,  though  there  is  good  reason  to 
believe  that  in  many  cases  the  predisposition  is  an  inherited  one,  while  in 
others  it  is  the  result  of  traumatisms  and  of  local  pathologic  lesions. 

Heredity. — It  is  generally  believed  that  certain  individuals  inherit 
a  predisposition  or  tendency  to  the  development  of  carcinomatous 
tumors;  and  that  the  disease  may  seemingly  be  transmitted  in  an  un- 
broken chain  for  several  generations,  or  may  show  itself  only  occasion- 
ally, skipping  one  or  two  generations  to  reappear  in  a  succeeding  one. 

There  is  no  more  reason  to  doubt  the  possibility  of  the  hereditary 
transmission  of  a  peculiar  condition  of  the  tissues  which  predisposes 
them  to  the  formation  of  carcinomatous  tumors  than  there  is  to  doubt 
the  possibility  of  certain  congenital  deformities,  peculiarities  of  physi- 
ognomy, or  mental  proclivities  being  directly  transmitted  from  parent 
to  child,  or  suppressed  for  a  time  to  reappear  again  several  genera- 
tions later,  or  in  a  distant  branch  of  the  family,  for  proofs  of  their 
occurrence  are  plentiful. 

Broca  has  placed  on  record  the  most  interesting  instance  of  inher- 
ited predisposition  to  carcinoma  that  can  be  found  in  medical  literature. 

Madame  Z.  died  of  cancer  of  the  breast,  in  1788,  at  the  age  of  sixty. 
Of  four  married  daughters, — 

A  died  of  cancer  of  the  liver  in  1820,  at  the  age  of  sixty-two;  B  in 
1805,  at  the  age  of  forty-three;  C  of  cancer  of  the  breast  in  1814,  at  the 
age  of  fifty-one;  D  in  1827,  at  the  age  of  fifty-four. 

Of  five  daughters  and  two  sons  born  to  Madame  B,  first  son  died 
in  infancy;  second  son  died  of  cancer  of  the  stomach,  at  the  age  of 
sixty-four;  first  daughter  died  of  cancer  of  the  breast,  at  the  age  of 
thirty-five;  second,  third,  and  fourth  daughters  died  of  cancer  of  the 
breast,  at  the  ages  of  thirty-five  to  forty.  The  fifth  daughter  escaped 
the  affection. 

Madame  C  gave  birth  to  five  daughters  and  two  sons.  Both 
sons  remained  free  from  the  disease.  The  first  daughter  died  of  can- 
cer of  the  breast,  at  the  age  of  thirty-seven.     This  woman  had  five 


CARCINOMATA.  53 1 

children, — one,  a  daughter,  died  in  1854,  of  cancer  of  the  breast,  at  the 
age  of  forty-nine.  The  second  claug'hter  of  Madame  C  died  of  cancer  of 
the  breast,  aged  forty ;  the  third  daughter  died  of  cancer  of  the  uterus, 
aged  forty-seven  ;  the  fourth  daughter  died  of  cancer  of  the  breast,  aged 
tifty-tive ;  the  fifth  daughter  died  of  cancer  of  the  Hvcr,  aged  sixty-one, 

Paget  has  found  carcinoma  of  the  uterus  in  three  successive  gen- 
erations,— grandmother,  mother,  and  daughter.  Sibley  has  seen  it  in 
two  generations.  Warren  has  related  an  instance  of  cancer  of  the  lip 
in  the  father  and  one  son,  and  cancer  of  the  breast  in  two  daughters. 

Senn  has  observed  cancer  of  the  breast  in  two  successive  genera- 
tions. 

Such  family  tendencies,  however,  though  proving  an  hereditary 
predisposition  in  certain  individuals  to  the  development  of  cancerous 
growths,  have  not  been  observed  in  sufficient  numbers  to  establish  the 
law  of  hereditary  transmission  of  the  disease.  Lebert,  out  of  102  cases, 
could  find  but  ten  who  had  ancestors  that  had  suffered  from  the  disease. 
Leroy  d'Etoilles  found  but  one  out  of  278  cases  giving  such  a  history. 
Gross  analyzed  1164  cases,  and  found  but  4.72  per  cent,  which  could 
give  a  history  of  this  character. 

Statistics  therefore  prove  that  hereditary  transmission  of  the  dis- 
ease is  rare. 

Bacteria, — During  the  past  few  years  considerable  interest  has 
been  awakened  in  the  question  of  the  microbic  origin  of  carcinomatous 
growths.  The  disease  presents  many  features  in  its  clinical  history 
which  point  to  an  infective  origin,  but  the  proofs  necessary  to  estab- 
lish the  fact  have  not  been,  up  to  this  date,  presented.  It  would  not  be 
wise,  however,  to  say  that  such  proofs  can  never  be  furnished,  for  the 
writer  remembers  that  such  statements  were  made  in  reference  to 
tuberculosis,  a  disease  which  was  thought  by  many  to  be  infectious  in 
character  long  before  the  bacteriologist  demonstrated  the  Bacillus 
tuberculosis  and  its  infectious  nature.  The  difficulties  which  stood  in 
the  way  of  demonstrating  the  presence  of  the  tubercle  bacillus  were 
largely  those  of  discovering  suitable  staining  reagents.  Difficulties 
now  confront  the  bacteriologist  in  his  efforts  to  demonstrate  a  cancer 
bacillus,  but  they  are  no  greater  than  those  overcome  in  relation  to 
tuberculosis. 

Binaghi,  in  a  recently  published  study  of  the  blastomyces  found  in 
certain  epitheliomata,  concludes,  from  the  constant  presence  of  parasitic 
forms  of  characteristic  features,  which  are  readily  distinguished  by 
coloring  agents  and  other  chemical  substances,  that  they  may  be  re- 
garded as  specific  blastomyces.  He  further  states  that  they  are  not 
found  in  other  tissues,  either  normal  or  pathologic ;  that  they  are  not 
accidentally  present,  but  are  causative  agents  of  the  disease.  This  he 
further  infers  from  their  regular  disposition  and  the  relation  which  they 
bear  to  the  cells  of  the  new  growth. 


532  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

To  establish  the  specific  nature  of  these  blastomyces  it  is  necessary 
to  produce  the  disease  in  susceptible  lower  animals  and  in  man  by  in- 
oculation with  them.  This  as  yet  has  not  been  accomplished.  It  is 
possible,  however,  that  a  micro-organism  may  yet  be  discovered  in 
carcinoma  which  will  fulfill  all  the  requirements  of  Koch's  law. 

The  discovery  of  such  a  micro-organism  would  work  a  complete 
revolution  in  the  generally-accepted  teaching  of  the  origin  of  carcino- 
matous tumors. 

Exciting  Causes. — The  presence  of  a  tumor-matrix  of  epithelial 
cells  in  mesoblastic  tissues  is  not  always  productive  of  the  develop- 
ment of  a  carcinomatous  tumor.  Such  a  matrix  may  remain  dormant 
to  the  end  of  life,  unless  stimulated  to  activity  by  some  agency  outside 
of  itself. 

Traumatisms,  inflammatory  lesions,  particularly  the  chronic  forms, 
continued  local  irritation,  and  senile  tissue-changes  are  potent  factors 
in  exciting  an  existing  tumor-matrix  to  active  cell-proliferation.  This 
may  be  explained  by  the  fact  that  tissues  which  have  suffered  damage 
of  any  sort  have  not  the  same  resistive  power  against  disease  that  was 
possessed  by  the  same  tissues  in  a  normal  state;  while  the  increased 
quantity  of  blood  supplied  to  the  part  suffering  from  injury  stimulates 
the  misplaced  epithelial  tissue  to  active  cell-proliferation. 

According  to  Paget,  about  one-fifth  of  those  who  are  the  victims  of 
carcinoma  ascribe  the  disease  to  some  form  of  injury.  In  some  cases, 
the  disease  follows  immediately  after  the  injury;  in  others  it  shows  itself 
at  a  more  remote  period;  while  in  another  and  larger  class,  repeated 
injuries  are  necessary  to  produce  such  a  result.  iSenn  believes  that  "no 
amount  or  kind  of  injury  will  produce  a  carcinoma  without  the  pres- 
ence of  the  essential  tumor-matrix." 

The  senile  tissue-changes  cause  the  development  of  such  neo- 
plasms by  diminishing  the  physiologic  resistance  of  the  tissues.  These 
changes  are  different  from  those  which  take  place  as  a  result  of  debili- 
tation from  disease  or  insufficient  nourishment,  as  is  evidenced  by  the 
fact  that  individuals  suffering  from  marasmus  caused  by  debilitating 
disease  or  starvation  are  no  more  liable  to  be  affected  by  carcinoma 
than  persons  of  the  same  age  who  are  in  other  respects  in  perfect 
health.     (Senn.) 

Thiersch  has  observed  that  in  the  lips  of  old  persons  the  fibrous 
tissue  wastes  away,  while  the  glandular  structures  increase  in  size,  thus 
predisposing  to  the  development  of  carcinomatous  tissue. 

Inflammatory  lesions  of  chronic  type  are  not  infrequently  the  ex- 
citing cause  of  carcinoma,  and  both  acute  and  chronic  inflammation, 
as  well  as  wounds  in  the  process  of  healing,  may  become  the  starting- 
points  of  carcinoma  by  the  inclusion  of  embryonic  epithelial  cells 
within  the  granulation  or  cicatricial  tissue,  thus  furnishing  not  only  the 
exciting  cause  of  the  disease,  but  the  post-natal  essential  cause  as  well. 


CARCINOMATA.  533 

Insignificant  injuries,  like  punctures,  abrasions,  and  slight  wounds, 
have  occasionally  been  the  only  recognized  exciting  cause  of  the 
disease. 

Irritation  of  a  continued  and  prolonged  character  is  the  most  com- 
mon exciting  cause  of  carcinoma,  as  is  evidenced  by  the  fact  that  carci- 
noma is  frequently  seen  in  those  localities  which  are  subjected  to  re- 
peated and  prolonged  irritation.  These  localities  are  situated  at  the 
entrances  of  the  body,  viz :  the  lips,  the  nose,  the  rectum,  the  labia,  and 
the  cervix  uteri. 

Prolonged  irritation  of  the  tongue  or  cheeks  from  the  sharp  edges 
of  carious  teeth,  or  from  accumulations  of  salivary  calculus,  are  often 
exciting  causes  of  cancerous  growths. 

Warts  and  moles  which  have  been  the  subjects  of  irritation  or  in- 
flammation, may  also  become  the  starting-points  of  carcinoma  of  the 
skin. 

Tubercular  lesions  of  the  skin  have  been  thought  to  be  productive 
of  carcinoma  from  the  inflammatory  irritation,  and  also  to  furnish  the 
essential  cause  by  the  inclusion  of  epithelial  elements  in  the  process  of 
healing. 

W.  Roger  Williams,  in  discussing  the  question  of  the  exciting 
causes  of  cancer  (London  Lancet,  1898),  advances  the  view  that  the 
tendency  in  those  predisposed  to  the  disease  may  be  increased  by  un- 
suitable modes  of  living,  and  decreased  by  the  observance  of  hygienic 
and  sanitary  laws.  He  says :  "Such  influences  as  are  comprised  under 
the  terms  alimentation  and  domestication  seem  to  me  to  be  of  para- 
mount importance.  Probably  no  single  factor  is  more  potent  in  deter- 
mining the  outbreak  of  cancer  in  the  predisposed  than  high  feeding. 
There  can  be  no  doubt  that  the  greed  for  food  manifested  by  modern 
communities  is  altogether  out  of  proportion  to  their  present  require- 
ments. Many  indications  point  to  the  gluttonous  consumption  of  meat, 
which  is  such  a  characteristic  feature  of  this  age,  as  likely  to  be 
especially  harmful  in  this  respect.  When  excessive  quantities  of  such 
highly  stimulating  forms  of  nutriment  are  ingested  by  persons  whose 
cellular  metabolism  is  defective,  it  seems  probable  that  there  may  be 
thus  excited  in  those  parts  of  the  body  where  the  vital  processes  are  still 
active,  such  excessive  and  disorderly  cellular  proliferation  as  may 
eventuate  in  cancer.  No  doubt  other  factors  co-operate,  and  among 
these  I  should  be  especially  inclined  to  name  deficient  exercise  and 
probably  also,  deficiency  in  fresh  vegetable  food." 

Diagnosis  and  Symptoms. — The  correct  and  early  diagnosis  of 
carcinoma  is  a  matter  of  the  greatest  importance  to  the  afflicted  indi- 
vidual, for  upon  it  rests  the  grave  question  of  life  or  death.  The  diag- 
nosis of  this  disease  is  sometimes  an  exceedingly  difificult  task,  and  the 
very  best  diagnosticians  do  not  always  succeed. 


534  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

The  difficulties  which  surround  the  diagnosis  of  the  disease  de- 
pend upon  the  stage  of  development  and  the  location  of  the  tumor.  In 
carcinoma  of  the  external  parts,  when  the  disease  is  in  an  advanced 
stage  of  development,  the  diagnosis  presents  no  difficulties;  but  when 
located  in  some  internal  organ  diagnosis  becomes  many  times  an  im- 
possibility, and  the  true  nature  of  the  disease  is  not  discovered  until 
after  death.  The  life  of  the  patient  depends  upon  an  early  and  positive 
diagnosis,  and  prompt  radical  measures  in  the  surgical  treatment. 

To  reach  an  early  diagnosis  requires  a  careful  consideration  of  the 
clinical  history,  of  the  family  history,  of  the  signs  and  symptoms  pre- 
sented, and  a  painstaking  examination  of  the  tumor  itself.  The  micro- 
scope only  will  reveal  the  epithelial  character  of  the  tumor,  and  such 
examination  should  always  be  made  when  possible.  The  presence  of 
embryonic  proliferating  epithelial  cells  in  mesoblastic  tissues  is  the 
most  reliable  evidence  of  the  carcinomatous  nature  of  the  tumor. 

When  doubt  exists  as  to  the  true  nature  of  a  suspicious  tumor,  in- 
oculation experiments  may  be  necessary  to  differentiate  between  car- 
cinoma and  an  infective  swelling.  In  the  diagnosis  of  doubtful  tumors 
the  age  of  the  patient  becomes  an  important  and  interesting  element, 
for  statistics  show  that  the  disease  is  most  prevalent  in  persons  of  mid- 
dle or  past  middle  life,  the  ratio  increasing  with  the  age.  All  unex- 
plainable  tumors,  therefore,  occurring  in  individuals  past  middle  life, 
should  be  diagnosed  as  suspicious  growths,  and  treated  accordingly. 

The  location  of  a  carcinoma  is  largely  influenced  by  the  sex  of  the 
patient.  Carcinoma  of  the  pyloric  orifice  of  the  stomach  and  of  the  lip 
are  most  common  in  men,  while  cancer  of  the  breasts  and  of  the  geni- 
tals are  most  common  in  women. 

Another  important  element  in  the  diagnosis  is  the  rapidity  of  the 
growth  of  the  tumor.  As  compared  with  the  benign  tumors,  carci- 
noma grows  much  more  rapidly,  and  on  this  account  might  be  mis- 
taken for  an  inflammatory  swelling.  In  differentiating  between  a 
carcinoma  and  an  inflammatory  swelling,  it  should  be  remembered 
that,  as  a  rule,  an  inflammatory  swelling  increases  in  size  much  more 
rapidly  than  a  carcinomatous  growth.  The  inflammatory  swellings 
for  which  carcinomas  may  be  mistaken  are  tuberculosis,  gumma, 
chronic  suppuration,  and  actinomycosis. 

Infection  of  neighboring  lymphatic  glands  is  an  important  symp- 
tom, and  one  of  common  occurrence  in  carcinoma;  but  this  is  not  a 
pathognomonic  sign,  as  it  may  occur  in  connection  with  certain  infec- 
tive swellings  and  tumors  of  different  structure  having  malignant  ten- 
dencies. 

Dilatation  of  the  superficial  veins  is  usually  present,  due  to  in- 
creased vascularity  or  to  obstruction  in  deep-seated  veins,  but  this  con- 
dition is  quite  as  common  in  infective  swellings  as  in  carcinoma. 


CARCINOMATA.  535 

Edema  is  also  present  in  carcinoma  in  those  cases  where  regional 
infection  has  caused  obstruction  of  the  lymphatic  or  venous  circulation, 
or  when  the  neoplasm  has  become  infected  with  pus-producing  bac- 
teria. 

Tenderness  and  pain  are  not  characteristic  symptoms  of  carci- 
noma, as  is  generally  supposed  by  the  laity.  These  symptoms  are 
nmcli  more  prominent,  as  a  rule,  in  infective  swellings  than  in  carci- 
noma, although  in  the  advanced  stages  of  the  disease  they  may  become 
more  or  less  marked.  Carcinoma  of  the  pyloric  orifice  of  the  stomach 
is  comparatively  a  painless  disease,  the  suffering  accompanying  it  being 
due  more  to  the  obstruction  of  the  orifice  from  the  growth  of  the  tumor 
than  from  the  tumor  itself.  .  Carcinoma  of  the  rectum  is  productive  of 
little  pain  except  during  the  passage  of  feces,  and  for  this  reason  it 
often  occurs  that  the  patient  has  been  affected  with  carcinoma  for  some 
time  before  seeking  advice,  thinking  all  the  time  that  the  case  was  one 
of  hemorrhoids.  Carcinoma  of  the  lips,  cheek,  and  tongue  is  not  usu- 
ally attended  with  much  pain.  The  sharp,  lancinating  pain  commonly 
described  as  characteristic  of  carcinoma  is  by  no  means  constantly 
present,  but  is  frequently  intermittent  in  type.  Tenderness  is  usually 
absent  in  carcinoma,  except  in  its  later  stages.  Redness  also  is  rarely 
present  except  when  the  skin  is  involved  and  about  to  break  down  with 
ulceration. 

One  of  the  most  characteristic  diagnostic  symptoms  of  carcinoma 
is  the  fixation  of  the  tumor.  Benign  tumors  are  usually  encapsulated, 
consequently  are  not,  as  a  rule,  fixed  to  surrounding  tissues  by  adhes- 
ions, but  are  freely  movable  in  all  directions.  In  carcinoma  the  oppo- 
site conditions  obtain,  for  this  is  an  infiltrating  tumor,  causing  immo- 
bility, and  having  well-defined  margins  and  a  nodulated  surface. 

Ulcerating  tumors  present  the  greatest  difficulties  in  the  diagnosis 
of  carcinoma.  Syphilis,  tuberculosis  (lupus),  and  chronic  ulcers  of  the 
leg  are  most  frequently  mistaken  for  carcinoma. 

In  cancer  of  the  breast,  as  soon  as  the  skin  breaks,  the  ulcer  shows 
a  marked  tendency  to  spread,  and  presents  the  typical  appearance  of  a 
cancerous  ulcer,  viz :  raised  and  rampart-like  edges,  surrounding  an  ir- 
regular depression,  the  floor  of  which  is  covered  with  firm  granulations, 
and  discharges  a  foul,  ichorous,  or  blood-stained  fluid.     (Sutton.) 

On  section  of  a  carcinoma  a  juice  exudes  from  the  cut  surfaces, 
which  is  very  characteristic  of  the  disease. 

The  constitutional  effect  produced  by  carcinoma  is  known  as  the 
cancerous  cachexia,  and  consists  in  rapid  emaciation,  anemia,  and  loss  of 
strength  (Warren),  but  the  means  by  which  these  conditions  are 
brought  about  are  not  understood. 

Prognosis. — The  prognosis  of  carcinoma  will  depend  very  largely 
upon  its  location,  its  histologic  character,  and  the  stage  of  its  devel- 
opment when  presenting  for  treatment. 


536  SURGERY    OF   THE    FACE,    MOUTH,   AND   JAWS. 

Carcinoma  of  the  skin  is  usually  the  squamous-celled  variety. 
This  is  much  more  chronic  in  its  course  than  either  the  cylindrical  or 
the  glandular-celled  variety,  and,  being  located  usually  upon  an  ex- 
posed surface  of  the  body,  attention  is  called  to  its  existence,  and  relief 
is  sought  at  a  much  earlier  period  than  when  the  disease  is  located  in  an 
internal  organ,  or  in  the  mucous  membrane  in  locations  which  cannot 
be  inspected  by  the  patient.  Under  the  latter  circumstances  the  dis- 
ease is  often  so  far  advanced  before  surgical  advice  is  sought,  that  radi- 
cal treatment  would  give  no  hope  of  eradicating  the  disease. 

A  favorable  prognosis  could  only  be  given  in  such  cases  as  had 
not  infected  the  nearest  lymphatic  glands,  nor  infiltrated  the  surround- 
ing tissues  to  any  considerable  degree,  and  in  such  a  location  as  to 
permit  of  its  complete  removal  by  a  radical  operation.  When  infiltra- 
tion is  extensive,  or  a  chain  of  glands  has  been  infected,  there  is  always 
considerable  doubt  existing  as  to  whether  all  infected  tissue  has  been 
removed.  In  a  large  majority  of  cases  the  inference  is  that  it  has  not 
been,  as  recurrence  after  a  few  months  is  the  usual  outcome  of  opera- 
tions performed  at  this  late  period. 

If  the  disease  has  reached  the  stage  of  the  formation  of  a  metas- 
tatic tumor,  or  of  miliary  carcinosis,  there  is  no  hope  of  saving  or  pro- 
longing the  life  of  the  patient,  either  by  operation  or  other  measures. 
The  average  duration  of  life  in  carcinoma,  if  unmolested,  is  from  two 
to  three  years.  (Senn.)  Some  authors  place  it  at  eighteen  months  to 
two  years.  The  duration  of  life  largely  depends  upon  the  malignancy 
of  the  tumor,  its  location,  and  the  vitality  of  the  patient.  Life  is  finally 
extinguished  as  the  result  of  metastasis,  septic  infection,  exhaustion,  or 
of  encroachment  of  the  primary  or  secondary  tumor  upon  vital  organs. 

Treatment. — All  modern  writers  are  agreed,  that  if  operative 
treatment  of  carcinoma  is  to  be  successful,  it  is  of  the  utmost  import- 
ance that  it  be  undertaken  early  in  the  history  of  the  disease.  Carcin- 
oma in  its  earliest  stages  has  a  benign  period,  and  if  removed  at  this 
time  has  no  more  tendency  to  recur  than  other  epithelial  tumors  which 
are  of  benign  character.  This  is  exemplified  in  the  early  excision  of 
carcinoma  of  the  lip,  which  if  thoroughly  removed  is  seldom  followed 
by  recurrence.  Cylindrical  and  glandular  carcinoma  may  also  be  as 
successfully  treated  by  excision,  provided  the  operation  can  be  made 
under  the  same  favorable  conditions.  Senn  believes  that  carcinoma  of 
the  breast  and  of  the  uterus  yield  as  satisfactory  results  if  operated 
upon  at  an  early  period, — while  the  disease  is  still  local  in  its  manifesta- 
tions,— by  the  removal  of  the  entire  organ,  as  does  excision  of  the  car- 
cinoma of  the  lip.  The  first  question  to  be  decided  in  every  case  of 
carcinoma  is,  Can  it  be  cured  by  a  radical  operation,  or  has  it  pro- 
gressed in  its  course  so  far  as  to  admit  only  of  palliative  treatment?  If 
operation  is  decided  upon,  the  knife  should  be  used  with  a  bold  and 


CARCINOMATA.  537 

fearless  hand,  and  the  entire  organ  affected  should  be  excised,  when 
practicable,  and  as  much  of  the  surrounding  healthy  tissue  removed  as 
can  be  done  with  safety. 

Operation  is  sometimes  recommended  as  a  palliative  measure,  for 
the  relief  of  pain,  and  for  the  purpose  of  removing  necrotic  tissue  and  a 
disgustingly-foul  ulcerating  sore. 

A  radical  operation  in  those  cases  in  which  it  is  impossible  to  re- 
move all  the  locally-infected  tissue,  or  in  which  the  lymphatic  glands 
are  involved  or  secondary  carcinoma  has  developed,  can  be  of  no  cura- 
tive value,  but  it  may  prolong  the  life  of  the  sufferer  for  a  few  months, 
and  this  for  various  business  and  family  reasons  is  sometimes  exceed- 
ingly desired  by  the  patient. 

Senn  gives  the  following  conditions  under  which  a  radical  opera- 
tion is  contra-indicated:  "First,  extreme  senile  marasmus;  second,  ex- 
tensive local  infection;  third,  regional  infection  beyond  the  reach  of 
complete  removal  of  all  the  infected  tissues;  fourth,  general  infection; 
fifth,  the  co-existence  of  another  disease  which  in  itself  will  prove  fatal 
in  a  short  time." 

The  great  majority  of  all  carcinomata  presented  to  the  surgeon  for 
treatment  have  passed  the  stage  when  a  radical  operation  would  ac- 
complish anything  more  than  temporary  relief.  It  is  a  sad  commen- 
tary upon  the  art  of  the  surgeon  that  poor  suffering  humanity  so 
dreads  the  knife  of  the  operator  that,  if  the  disease  is  seen  in  time  to 
save  life  by  an  operation  and  this  is  advised  as  the  only  safe  course,  the 
great  majority  will  decline,  or  procrastinate  until  it  is  too  late  to  be  of 
benefit.  But,  when  they  realize  this  fact,  they  are  then  not  only  will- 
ing to  submit  to  an  operation,  but  sometimes  demand  that  it  be  done, 
even  at  the  risk  of  their  lives  while  upon  the  operating-table. 

The  wound  following  an  operation  for  the  removal  of  carcinoma 
should  be  immediately  covered  with  integument.  If  this  cannot  be 
accomplished  by  drawing  the  edges  of  the  wound  together  by  sutures, 
a  flap  of  skin  should  be  raised  in  the  immediate  neighborhood,  suffi- 
cient to  cover  it;  or,  if  this  is  not  practicable,  skin-grafting  after  the 
method  of  Thiersch  may  be  resorted  to.  Healing  of  the  wound  by  first 
intention  is  exceedingly  desirable,  and  every  effort  should  be  made  to 
secure  it. 

The  application  of  caustics,  arsenic,  chlorid  of  zinc,  etc.,  as  a  radi- 
cal method  of  treatment,  is  not  to  be  recommended,  except  in  those 
cases  in  which  the  patient  will  not  submit  to  excision;  their  use,  how- 
ever, even  under  such  circumstances,  should  be  restricted  to  small- 
sized  carcinomata  of  the  skin.  The  removal  of  cancerous  growths  by 
the  aid  of  caustics  is  m.uch  more  painful  than  by  excision  with  the  knife 
while  the  patient  is  under  the  influence  of  local  or  general  anesthetics. 
The  operation  by  caustics  also  requires  much  more  time  both  for  the 


538  SURGERY    OF   THE    FACE,    MOUTH,   AND   JAWS. 

removal  of  the  tumor  and  for  the  heahng  of  the  wound,  while  the  cos- 
metic effect  is  not  so  good,  as  it  invariably  leaves  a  large  scar. 

Palliative  treatment  in  the  non-ulcerative  form  consists  of  opium 
to  relieve  pain,  and  local  applications  of  lead-water  and  tincture  of 
opium,  or  other  soothing  remedies.  In  ulcerative  carcinoma  the  sur- 
face may  be  dusted  with  iodoform  and  morphia;  cocain  solution 
painted  or  sprayed  upon  the  surface  will  also  relieve  the  pain.  The 
fetor  of  the  discharges  may  be  lessened  by  the  use  of  carbolic  acid  solu- 
tions, phenol  sodique,  cinnamon  water,  or  a  solution  of  chloral.  The 
employment  of  dry  boric  acid  dressings  is  also  valuable  for  the  same 
purpose,  as  they  favor  rapid  drying  of  the  discharges,  and  prevent 
putrefaction. 


CHAPTER    LIII. 

CARCINOMATA  (Continued). 

The  varieties  of  carcinoma  which  are  of  the  greatest  interest  to  the 
student  of  oral  surgery  are  those  which  appear  upon  the  integument  of 
the  face,  upon  the  hps,  the  oral  mucous  membrane,  the  pharynx,  the 
tonsils,  the  tongue,  and  the  salivary  glands. 


Epithelial  cells 
in  masses. 


Stroma 


Carcinoma — Epithelioma:  General  Type  of  this  Form  of  Growth.    X  5° 


The  varieties  of  carcinoma  which  are  found  afifecting  the  super- 
ficial surfaces  of  the  skin,  the  mucous  membrane,  and  the  tongue,  as 
well  as  those  which  attack  the  glandular  structures  of  these  tissues,  are 
commonly  classed  under  the  head  of  epithelioma.     (Fig.  239.)     This 

539 


540 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


term  came  into  use  before  it  was  discovered  that  all  forms  of  carcinoma 
are  epitheliomatous  (epithelial)  growths,  and  was  originally  applied  to 
a  form  of  cancer  located  in  the  epithelial  tissue  of  the  skin.  Fig.  240 
is  from  an  epitheloma  of  the  skin  of  the  abdomen.  Fig.  241  illus- 
trates the  microscopic  appearance  of  chimney-sweep's  cancer  of  the 
scrotum. 

Carcinoma  of  the  Skin. — Squamous-celled  carcinoma  (epithelioma 
of  the  skin)  may  develop  in  any  portion  of  the  body  where  a- 
squamous  or  stratified  epithelium  may  be  found,  but  it  is  most  fre- 

FiG.  240. 


Epithelial  I 
cell  nest    " 


Stroma. 


Epithelioma  of  Skin  (Abdomen).    X  500. 


quently  located  in  those  portions  where  the  skin  and  mucous  mem- 
brane come  into  relation  with  each  other,  and  at  which  point  there  is  a 
transition  from,  the  ^trajijEied  to  the  columnar  form  of  epithelium. 

Carcinoma  of  the  skin  differs  histologically  from  the  benign  forms 
of  epith'elkr  tumor  (papillomata)  in  the  fact  that  it  is  not  confined  to  the 
epithelial  tissues  of  the  skin,  but  passes  the  boundaries  of  the  basement 
membrane-,  and  involves  the  surrounding  connective  tissue.  Accom- 
panying this  invasion  of  the  connective  tissue  there  is  developed  a 


CARCINOMATA, 


541 


peculiar  arrangement  of  the  epithelial  cells  known  as  "cell-nests,"  or 
"epithelial  nests." 

These  tumors  usually  make  their  appearance  upon  the  surface  of 
the  skin,  either  as  warty  growths,  as  slight  cracks  or  fissures  covered 
by  a  scab  or  crust,  or  as  flattened  tubercles.  The  base  is  hard,  the  mar- 
gins indurated,  and  the  tumor  sometimes  slightly  elevated  above  the 
surrounding  skin.  In  all  these  forms,  ulceration  sets  in  early.  Some- 
times the  ulcer  will  possess  raised,  rampart-like  edges ;  in  another  form, 

Fig.  241. 


Epithelial  nests 
formed  by 


pressure  from 
stroma. 


Chimney-sweep's  Cancer  OF  Scrotum.    (T.  Charters  White.)     X  100. 

instead  of  raised  edges,  the  margins  will  be  sharply  defined;  while 
occasionally,  in  still  another,  the  edges  will  be  undermined.  The  ulcer- 
ation which  takes  place  is  due  to  a  defective  blood-supply  of  the  cells 
forming  the  central  or  oldest  portion  of  the  initial  tumor,  which  results 
in  their  death. 

The  tendency  of  primary  carcinoma  of  the  skin  in  the  ulcerative 
stage,  when  left  to  itself,  is  to  spread,  and  to  involve  extensive  areas  of 
tissue,  or  to  form  fungous  masses,  or  by  gigantic  granulations  to  form 
large  cauliflower-like  excrescences.     Accompanying  these  conditions 


542 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


is  a  foul,  fetid  discharge,  in  which  are  found  small  masses  of  dead  tissue, 
cell  debris,  and  blood.  In  its  most  malignant  form,  the  surrounding 
tissues,  either  skin,  muscle,  or  mucous  membrane,  are  quickly  invaded 
and  destroyed,  while  the  bone  even  is  attacked  and  rapidly  destroyed 
by  erosion  and  necrosis.  Cartilage  alone  resists  the  invasion  of  the 
disease. 

Fatty  degeneration  is  the  most  common  retrograde  change  that 
takes  place  in  carcinoma  of  the  skin.     Colloid  degeneration  is  more 

Fig.  242. 


Pearl  bodies. 


Horny  cell-nests. 


Carcinoma— Epithelioma— SHOWING  Pearl  or  Colloid  Bodies.    X  75- 


rare.    In  the  warty  form  the  processes  which  project  from  the  skin  are 
sometimes  quite  horny  in  their  hardness.     (Figs.  242  and  243.) 

Histologically  all  of  these  varieties  of  carcinoma  of  the  skin  are 
identical  in  their  structure.  Sections  of  these  neoplasms  so  cut  as  to 
include  the  edge  of  the  ulcer  and  the  adjoining  tissue  also,  will  show 
the  surface  epithelium  dipping  down  into  the  connective  tissue  be- 
neath, in  the  form  of  long  projections,  "columns,"  or  "plugs."  The 
tissues  about  these  epithelial  projections  are  infiltrated  with  epithelial 


CARCINOMATA. 


543 


cells  (Sutton),  while  scattered  among  these  projections  and  within 
fhem  in  various  locations  are  found  those  "peculiar  concentric  cellu- 
lar bodies"  designated  as  epithelial  nests.  A  peculiarity  of  the  epi- 
thelial projections  is  that  they  have  no  limiting  membrane,  and  that 
many  of  the  larger  projections  branch  and  unite  with  neighboring  col- 
umns, forming  a  sort  of  net-work  or  reticulum.  "Cell-nests"  are  a 
peculiarity  of  all  forms  of  skin  carcinoma,  but  though  the  size  of  the 


Fig.  243. 


Colloid  degener- 
ation. 

;     --■■ 

W 

Carcinoma  cells 
degenerating. 


Carcinoma— SHOWING  Colloid  Degeneration.    X  70- 


epithelial  projections  and  the  number  of  the  cell-nests  may  vary  in  the 
different  forms  of  the  disease,  the  general  plan  of  the  extension  of  the 
tumor  is  the  same  in  all.     (Fig.  244.) 

The  locations  in  which  this  form  of  carcinoma  is  found  are  the 
face,  the  lips,  the  eyelids,  the  buccal  aspect  of  the  cheeks,  the  esopha- 
gus, the  edges  of  old  scars,  and  various  other  portions  of  the  body 
which  are  not  of  especial  interest  in  this  connection. 

Carcinoma  of  the  Face.— The  face  is  the  most  frequent  location 
of  carcinoma  of  the  skin.    Out  of  740  cases  of  tumors  of  all  kinds,  sub- 


544 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


jected  to  operative  treatment,  O.  Weber  found  133  cases  of  carcinoma 
of  the  face,  or  17.97  per  cent. 

It  occurs  more  frequently  in  men  than  in  women.  V.  Ziemssen 
collected  948  cases  of  carcinoma  of  the  skin;  of  these  739  (77.95  per 
cent.)  were  in  men,  and  209  (22;05  per  cent.)  were  in  women,  showing 
the  disease  to  be  about  three  and  one-half  times  more  frequent  in  men 
than  in  women. 

The  period  of  life  in  which  carcinoma  of  the  skin  is  most  common 
is  between  forty  and  eighty  years  of  age.  The  age  at  which  it  has  been 
most  frequently  seen  is  between  fifty-five  and  sixty. 

Fig.  244. 


Carcinoma  OF  Skin  OF  Nates.    X  ho.    Reduced  one-third.     (After  Senn.) 


a,  hypertrophied  stratum  corneum;  ^i,  growth  of  epithelial  cells  into  subcutaneous  tissue  ;  c,  epithe- 
lial nest  in  vascular  connective-tissue. 

Carcinoma  of  the  skin,  according  to  Thiersch,  appears  in  two 
forms, — one  a  superficial  ulceration  (rodent  ulcer),  and  the  other  pene- 
trates deeply  into  the  tissues,  and  successively  involves  the  different 
structures.  This  is  called  the  deep-seated,  penetrating,  or  polymor- 
phous-cell cancer. 

The  superficial  variety  of  carcinoma,  ''rodent  ulcer,"  is  almost 
always  found  upon  the  face,  and  is  frequently  preceded  or  accompanied 
by  keratosis,  a  thickening  of  the  epidermis,  and  the  presence  of  such 
callosities  as  warts,  horns,  etc. 

Superficial  carcinoma  is  characterized  by  the  formation  of  scabs 


CARCINOMATA.  545 

or  crusts,  which  may  exist  for  a  long  time  before  any  maHgnant  ten- 
dency is  manifested.  They  appear  first  as  scales,  slightly  elevated  above 
and  'somewhat  darker  than  the  surrounding  skin.  The  surface  is 
sometimes  smooth  and  shining,  and  at  others  covered  with  slightly 
adherent  scabs.  The  elevated  spots  are  not  sensitive,  and  when  the 
crust  is  removed  leave  an  exposed  superficial  excoriation.  This  vari- 
ety of  carcinoma  does  not  usually  appear  until  after  middle  life,  is  ex- 
tremelv  slow  in  its  development,  is  painless,  and  on  this  account  does 
not  cause  any  anxiety  as  to  its  nature,  until  it  has  assumed  considerable 

dimensions. 

Histologically,  if  the  tumor  is  composed  of  squamous  cells  it  ap- 
pears from  the  beginning  as  an  infiltration  with  small  epithelial  cells, 
which,  before  ulceration  occurs,  fill  the  alveoli  of  the  stroma.  If  it 
arises 'from  the  glandular  appendages  of  the  skin,  the  columnar  epi- 
thelial cells  will  be  found  arranged  in  groups  resembling  the  tubular 
glands.  (Senn.)  In  the  early  stage  of  ulceration  the  ulcer  is  not  deep ; 
its  surface  is  quite  flat  and  bounded  by  a  pearl-colored  rim,  the  shape 
often  resembling  a  horn  waistcoat  button.  (Warren.)  The  ulcerative 
process  from  this  time  progresses  by  an  unequal  extension  m  different 
directions,  so  that  the  surface  of  the  ulcer  presents  a  very  irregular 

outline. 

In  this  form  of  the  disease  glandular  infection  usually  comes  late 
in  the  life-history  of  the  disease;  for  this  reason  operative  procedures 
are  more  liable  to  prove  curative  than  in  other  forms  of  carcinoma.  ^ 

In  the  superficial  form  the  ulceration  takes  place  rapidly,  but  it  is 
confined  to  the  skin;  while  in  the  deep-seated  or  penetrating  form,  be- 
sides spreading  in  various  directions,  it  also  extends  downward,  in- 
volving the  tissues  beneath  its  base  regardless  of  their  structure,  be  it 
connective  tissue,  muscle,  or  bone. 

Carcinoma  of  the  face  most  often  attacks  the  upper  portions;  the 
frontal  and  malar  regions,  the  eyelids,  and  the  nose.  Frightful  deform- 
ities are  sometimes  produced  by  the  extension  of  the  disease.  Warren 
describes  a  case  in  which  the  disease  originated  in  the  scar  of  a  gun- 
shot wound  received  in  the  civil  war,  and  had  destroyed  the  side  of  the 
nose,  the  eye,  the  ear,  and  the  cheek,  including  the  corresponding  half 
of  the  upper  and  lower  lips. 

Diagnosis.— In  the  diagnosis  of  carcinomatous  growths  of  the  face 
it  must  be  borne  in  mind  that  there  are  certain  diseases  which  may  be 
located  in  the  face,  such  as  tuberculosis,  syphilis,  suppurative  condi- 
tions of  benign  tumors,  and  retention  cysts  (Senn),  which  may  mislead 
even  careful  observers.  Tuberculosis  of  the  skin  of  the  face  may  so 
nearly  resemble  carcinoma  as  to  make  it  impossible  to  dififerentiate 
them'  without  the  microscope  and  inoculative  experiments.  Tertiary 
syphilitic  afTections  of  the  skin  may  usually  be  differentiated  from  car- 


546  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

cinema  by  the  presence  of  scars  from  syphilitic  lesions  which  have 
healed.  Doubt  as  to  the  nature  of  the  disease  may  be  cleared  up  by  a 
resort  to  anti-syphilitic  treatment  for  a  few  weeks,  when  improvement 
will  soon  be  manifest  if  the  disease  is  syphilis. 

Prognosis. — ^The  superficial  variety  of  this  disease  in  its  early  stage 
gives  all  the  evidence  of  a  benign  growth,  but  there  is  a  period  in  its 
history  when  for  some  unexplainable  reason  it  suddenly  takes  on  a 
malignant  form,  and  the  superficial  variety  of  the  disease  is  changed 
to  the  penetrating  or  deep  variety.  The  slight  malignancy  of  these 
ulcerating  forms  of  the  disease  is  thought  to  be  due  to  the  feeble  re- 
productive power  of  the  small  epithelial  cells,  but  Warren  "thinks  it 
more  probable  that  there  are  other  factors  to  be  considered,  such  as  the 
anatomical  seat  of  the  disease,  and,  possibly,  the  nature  of  the  para- 
site,— if  there  be  one, — which  caused  it." 

The  prognosis  is  much  more  unfavorable  in  the  deep-seated  vari- 
ety of  the  disease  than  in  the  superficial  form,  as  the  ulceration  spreads 
rapidly,  and  results  in  extensive  destruction  of  the  various  tissues  sur- 
rounding it  in  a  remarkably  short  space  of  time.  Warren  looks  upon 
the  region  of  the  nasal  process  of  the  superior  maxilla  as  one  of  the 
most  dangerous  and  "important  strategic  points"  in  cancer  of  the  face, 
for  the  reason  that  carcmoma  originating  here,  or  encroaching  upon 
the  inner  margin  of  the  orbit,  may  suddenly  involve  the  lymphatics 
leading  to  the  base  of  the  skull.  He  looks  upon  the  disease  as  incur- 
able after  it  has  once  passed  the  margin  of  the  orbit.  Recurrence  is 
the  rule,  though  occasionally  a  permanent  cure  takes  place.  If  the  dis- 
ease does  not  return  in  five  years,  the  cure  may  be  considered  as  per- 
manent. 

Treatment. — The  treatment  of  superficial  carcinoma — rodent  ulcer 
— by  caustics  may  sometimes  be  successful  if  begun  in  the  early  history 
of  the  disease  and  persistently  followed  up. 

Dr.  W.  A.  Pusey  reports  in  the  Clinical  Reviezv  (January,  1901), 
eleven  consecutive  cases  of  cutaneous  epithelioma  (rodent  ulcer) 
treated  in  loco  by  curetting  and  cauterization,  which  had  proved  suc- 
cessful, as  shown  by  the  fact  that  there  had  been  no  recurrence  after 
a  period  of  more  than  three  years.    He  says : 

"Cutaneous  epithelioma  is  the  form  of  carcinoma  which  theo- 
retically should  ofTer  the  most  favorable  conditions  for  successful  treat- 
ment. Carcinomas  occurring  in  other  tissues  are  often  out  of  reach 
of  discovery  until  they  furnish  some  indirect  evidence  of  their  exis- 
tence or  until  they  become  of  sufficient  size  to  be  palpable.  That  means 
that  their  presence  usually  escapes  notice  until  long  after  danger  of 
contaminating  adjacent  tissues  has  arisen.  With  epitheliomas  the  con- 
ditions are  different.  They  are  open  to  direct  inspection,  and  are  suffi- 
ciently characteristic  to  be  recognizable  from  the  time  of  the  develop- 


CARCINOMATA.  547 

ment  of  the  first  nodule.  They  are  slower  in  g-rowth  and  show  less 
destructive  tendencies  than  any  other  variety  of  carcinoma.  Moreover, 
situated  as  they  are  upon  the  surface,  where  their  growth  is  not  under 
pressure,  the  danger  of  metastasis  is  reduced  to  a  minimum.  The 
conditions  surrounding  epitheliomas,  therefore,  are  such  that  their 
treatment  should  be  successful  if  treatment  is  to  be  successful  in  can- 
cers at  all.  These  favorable  conditions  for  treatment  are  generally 
recognized.  There  is  also,  of  course,  general  agreement  that  the  only 
safe  method  of  treatment  of  epitheliomas,  as  of  other  forms  of  carcin- 
oma, is  complete  removal.  But  when  we  come  to  the  methods  of  re- 
moval there  is  a  divergence  of  opinion.  Surgeons  generally  advocate 
the  wide  excision  of  the  growth,  some  of  them  the  removal  of  contigu- 
ous glands  at  the  same  time.  Many  dermatologists,  on  the  other  hand, 
believe  that  certain  of  these  growths  may  be  as  thoroughly  removed  by 
measures  which  destroy  the  growth  in  loco,  without  so  great  loss  of 
surrounding  healthy  tissue  or  so  much  of  a  surgical  procedure.  The 
removal  by  non-surgical  methods  has  suffered  in  prestige  because  it 
has,  save  for  the  dermatologists,  been  left  largely  in  the  hands  of 
irregulars. 

"Clinically,  a  sharp  distinction  may  be  made  between  superficial 
and  deep-seated  epitheliomas.  Deep-seated  epitheHomas  begin  well 
down  in  the  subcutaneous  tissue.  At  an  early  stage  they  are  usually 
seen  as  hard  nodules  as  large  as  a  hazelnut,  well  down  under  the  skin ; 
these  usually  break  down  quickly,  forming  deep,  excavated  ulcers  which 
grow  rapidly,  causing  in  a  few  months  as  much  destruction  of  tissue 
as  is  ordinarily  seen  in  the  superficial  variety  only  after  years.  They 
quickly  involve  the  lymphatics  and  show  in  general  the  malignant  char- 
acteristics of  the  pent-up  carcinomas.  This  form  of  epithelioma  does 
not  present  proper  conditions  for  treatment  in  any  other  way  than  by 
radical  extirpation  with  the  knife.  Superficial  epitheliomas  pursue  a 
much  less  active  course.  Such  epitheliomas  may  persist  for  years  as  a 
group  of  small  nodules  or  as  insignificent  ulcers  remaining  freely  mov- 
able upon  the  subjacent  tissues.  Their  growth  is  slow  and  is  usually 
along  the  surface  and  not  downward.  Metastases  occur  ordinarily 
only  late  in  their  course.  If  left  alone  they  in  time  develop  the  destruc- 
tive characteristics  of  other  carcinomas.  But  that  is  late,  and  before 
that  time  arrives  they  have  usually  gone  through  a  long  period  of  slow 
growth  at  any  time  during  which  they  might  have  been  successfully  re- 
moved. This  is  the  form  of  epithelioma— and  it  is  an  easily  recognized 
variety— in  which  treatment  by  other  methods  than  the  knife  offers  the 
best  results.  I  venture  to  emphasize  the  relatively  mild  course  of  super- 
ficial epitheliomas  because  it  is  often  lost  sight  of  and  as  often  denied. 
The  statement,  for  example,  that  any  form  of  carcinoma  is  slow  to  in- 
volve the  lymphatics  will  meet  with  denial,  and  yet  there  can  be  no 


548  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

doubt  of  the  fact.  It  is  wonderful,  indeed,  the  length  of  time  an 
epithelioma  may  exist  and  the  amount  of  destruction  of  superficial 
tissue  it  may  occasion  without  secondary  involvement  of  other  tissues. 
I  have  seen,  within  a  few  weeks,  a  case  which  is  under  treatment  from 
time  to  time  in  one  of  the  large  hospitals  in  Chicago — an  old  woman 
with  an  epithelioma  on  the  back ;  it  has  persisted  for  years  until  it  now 
involves  an  area  on  her  back  and  shoulders  of  almost  two  square  feet  in 
extent,  and  there  is  even  now  no  evidence  of  metastasis. 

"The  diagnosis  in  all  of  the  cases  except  one  was  confirmed  by 
microscopical  examination.  That  successful  results  have  followed  in 
these  cases  without  exception  is  not  offered  as  anything  extraordinary, 
but  merely  as  the  result  which  may  be  reasonably  expected  under  simple 
methods  of  treatment,  provided  the  cases  are  taken  in  time  and  the. 
treatment  is  thorough  enough  to  destroy  the  diseased  tissue  in  loco. 

"The  method  of  treatment  which  was  pursued  in  all  of  these  cases 
was,  first,  curetting  as  thoroughly  as  possible,  and  then  the  application 
of  a  caustic,  usually  pyrogallic  acid.  In  all  cases  the  work  was  done 
under  cocain.  The  curetting  of  these  cases  is  made  easy  because  of 
the  softness  and  friability  of  the  diseased  tissue.  The  curetting  should 
be  done  until  tissue  resistent  to  the  curette  is  reached.  For  cleaning  out 
sm.all  pockets  I  use  a  very  small,  sharp  spoon.  It  must  be  remembered 
in  treating  all  epitheliomas  that  rootlets  of  the  growth  spread  beyond 
the  point  of  apparent  disease.  The  use  of  the  curette  alone  is  not 
sufficient  to  get  rid  of  these ;  it  is  for  that  reason  that  the  curetting 
should  be  fortified  by  the  use  of  a  caustic.  The  use  of  pyrogallic  acid 
after  curetting  has  given  satisfactory  results  in  my  hands.  Pyrogallic 
acid,  however,  is  a  very  mild  caustic,  and  I  have  given  it  up  within 
the  last  year  because  I  believe  it  is  less  safe  than  a  caustic  which 
more  surelv  destroys  diseased  tissue.  I  have  in  recent  cases  used 
instead  a  saturated  solution  of  zinc  chlorid  with  most  satisfactory 
results.  In  treating  these  cases  one  must  never  lose  sight  of  the 
fact  that  a  sharp  inflammatory  reaction  and  considerable  destruction 
of  tissue  beyond  the  point  of  apparent  disease  should  be  produced. 
The  ulcer  which  results  after  the  slough  has  come  ofif  should  be  kept 
clean  and  the  formation  of  a  scab  should  never  be  allowed  to  occur. 

"The  advantages  of  this  method  of  treatment  lie  in  the  direction 
of  convenience  and  of  cosmetic  results.  Patients  with  epitheliomas  will 
not  often  readily  submit  to  a  cutting  operation ;  they  are  inclined  to  put 
it  off  to  see  what  happens,  and  thus  critically  valuable  time  may  be  lost. 
And  even  where  they  will  submit  to  the  knife,  the  surgical  removal  of  a 
mass  of  tissue,  with  the  probable  accompaniments  of  an  anesthetic  and 
a  plastic  operation  afterward,  is  a  serious  matter  in  many  old  people 
who  present  themselves  with  epitheliomas. 

"If,  however,  there  were  good  clinical  grounds  for  believing  that 


CARCINOMATA.  549 

metastases  were  to  be  expected  in  these  superficial  epitheliomas  there 
could  be  no  justification  in  advocating  anything  less  than  a  radical 
operation.  But  the  facts  are  that  metastases  are  a  remote  possibility  in 
superficial  epitheliomas— a  possibility  quite  as  remote  as  that  of  undoing 
the  patient  bv  a  radical  operation.  The  cosmetic  results  of  curetting  or 
the  use  of  destructive  pastes  are  better  than  can  be  ordinarily  gotten 
from  the  use  of  the  knife.  With  the  knife  one  must  go  well  out  into  the 
healthy  tissue,  and  in  important  localities,  like  the  lower  lip,  the  eyelid, 
or  the  ala  of  the  nose,  the  loss  of  tissue  is  a  matter  of  serious  impor- 
tance. Bv  the  aid  of  caustics  you  are  able  to  limit  destruction  in  hrge 
part  to  the  diseased  tissue,  and  as  a  result  get  a  minimum  of  scar." 

The  operative  treatment  of  carcinoma  of  the  face,  to  be  successful, 
must  be  undertaken  at  a  period  prior  to  its  infection  of  the  lymphatics 
of  its  neighborhood.    The  tendency  of  the  disease  to  extend  toward  the 

Fig.  245. 


Partial  Rhinoplasty  by  taking  a  Flap  from  the  Opposite  Side  of  the  Nose. 
(After  Langenbeck.) 

orbit,  and  involve  the  eve,  makes  it  imperative  that  operative  interfer- 
ence should  take  place  before  the  orbit  is  reached.  The  eyelids  and  the 
side  of  the  nose  are  quite  frequently  the  seat  of  the  disease,  and  some- 
times extensive  operations  are  required  for  its  removal.  The  defects 
left  bv  the  removal  of  the  cancerous  growths  are  to  be  remedied  by 
plastic  operations  and  skin-grafting.  When  the  lower  eyelid  has  to 
be  removed,  the  defect  may  be  most  satisfactorily  remedied  by  Dieffen- 

bach's  method. 

Carcinoma  affecting  a  portion  only  of  one  ala  of  the  nose  may  be 
removed  by  cutting  out  a  wedge-shaped  piece  of  the  entire  thickness 
of  the  ala,  and  closing  the  defect  by  taking  a  flap  from  the  opposite  side 
of  the  nose,  after  the  method  of  Langenbeck  (Figs.  245.  246),  or  from 
the  face,  after  the  manner  of  Esmarch  (Fig.  247)-  Thiersch  grafts 
should  be  used  to  cover  the  wound  left  by  the  removed  flap.  Wlien 
the  tumor  involves  the  bridge  of  the  nose  and  the  bone  has  become 
infected,  an  extensive  operation  becomes  necessary,  requiring  the  re- 
moval of  the  bony  framework,  and  sometimes  of  considerable  portions 
of  the  nasal  mucous  membrane,  as  well  as  the  integument.     In  those 


550 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


cases  where  the  tip  of  the  nose  and  the  nasal  apertures  have  not  been 
involved  in  the  operation,  Konig's  flap  operation  will  correct  the  defect 
in  an  admirable  manner,     (Figs.  248,  249,  250.)    When  all  of  the  nose 

Fig.  246. 


Partial  Rhinoplasty  Complkted.     (After  Langenbeck.) 

Fig.  247. 


Partial  Rhinoplasty  by  taking  a  Pedunculated  Flap  from  the  Face  along  thk  Base  of 

THE  Nose.     (After  Esmarch.) 


Fig.  248. 


Konig's  Rhinoplasty. 
a,b,  flap  for  building  nose,  including  skin,  periosteum,  and  a  thin  slice  of  bone ;  5,  flap  used  to 
cover  flap  a,  and  to  furnish  integument  for  the  entire  defect ;  c,  defect  caused  by  excision  of  tumor. 


CARCINOMATA. 


551 


has  been  sacrificed,  Thiersch's  operation  for  restoring  the  lost  organ 
may  be  resorted  to.     (Fig.  251.) 

The  excision  of  carcinomatous  growths  in  other  portions  of  the 
face  should  be  performed  with  the  same  desire  for  thoroughness.     In 

Fig.  249. 


Konig's  Rhinoplasty. 
a,  flap  turned  downward  ;  b,  lower  end  fastened  in  place  with  catgut  sutures.    The  skin  at  the  top 
of  the  nose  at  b  is  left  free,  and  to  it  flap  b  is  sutured. 

Fig.  250. 


Konig's  Rhinoplasty. 
a,  b,  defects  over  the  frontal  bone;  c,  flap  b  which  covers  the  bony  surface  of  flap  a,  and  furnishes 
the  cutaneous  covering  for  the  entire  defect,  sutured  in  place. 

removing  these  tumors,  it  is  better  to  sacrifice  a  little  healthy  tissue, 
and  gain  a  successful  issue  of  the  operation,  than  to  insure  a  speedy 
recurrence  by  carrying  the  incision  so  close  to  the  growth  that  some 
portion  of  the  infected  tissue  is  left  behind.  The  defects  caused  by  the 
operation  should  be  remedied  by  bringing  the  edges  of  the  wound  to- 


552 


SURGERY    OF   TKE    FACE,    MOUTH,    AND    JAWS. 


gether  with  sutures,  or  by  a  flap  operation,  and  when  this  is  not  possi- 
ble, by  Thiersch  skin-grafts. 

Recurrence  is  to  be  looked  for,  and  repeated  operations  may  be 
required  to  eradicate  the  disease;  but  so  long  as  lymphatic  infection  has 
not  taken  place  and  there  is  no  evidence  of  other  than  local  disease, 
there  is  hope  of  a  final  cure. 

Fig.  2;i. 


Rhinoplasty.    (After  Thiersch.) 


Warren  mentions  a  case  of  a  gentleman  who  allowed  a  cancer  to 
grow  upon  the  left  side  of  the  nose  until  it  involved  the  skin  of  that  side, 
and  a  portion  of  the  right  side.  The  disease  returned  three  times. 
Finally  the  left  half  of  the  nose  and  the  nasal  process  of  the  superior 
maxilla  were  excised,  and  the  cavity  thus  left  was  covered  by  a  flap 
taken  from  the  foretiead.  The  disease  did  not  return  after  this,  the 
fourth  operation. 


CHAPTER    LIV. 


CARCINOMATA  (Continued). 

Carcinoma  of  the  Lip. — Carcinoma  situated  in  the  lip,  like  carci- 
noma in  general,  rarely  develops  until  after  middle  life.  It  is  most 
frequently  seen  between  the  fortieth  and  sixtieth  years. 

The  deep-seated,  penetrating,  or  polymorphous-cell  carcinoma  is 
typically  represented  in  carcinoma  of  the  lip.  The  disease  usually 
commences  at  the  border  of  tKe  lip,  at  the  junction  of  the  mucous  mem- 
brane with  the  skin  (Fig.  252),  and  its  first  appearance  is  either  in  the 

Fig   252. 


Carcinoma  of  the  Lower  Lip.     (After  Senn.) 


form  of  a  small  papule,  or  as  a  flat  crust  (Warren)  which  frequently 
scales  off  only  to  be  re-formed  again.  It  rarely  occurs  at  the  angles 
of  the  mouth,  or  upon  the  upper  lip.  (Fig.  253.)  The  general  appear- 
ance of  the  disease  in  its  early  stage  is  that  of  a  superficial  infiltration 
of  the  vermilion  border  of  the  lip,  having  a  well-defined  indurated  out- 
line. Later  ulceration  of  the  indurated  area  takes  place  in  the  center, 
from  which  may  be  squeezed  the  atheromatous  contents  of  the  exposed 
epithelial  cell-nests.  It  then  presents  a  shallow,  ulcerated  surface  with 
circular  outline  and  elevated  overhanging  edges.      (Fig.  254.)     With 

553 


554  SUROERV    OF    THE    FACE,    MOUTH,    AXD    JAWS. 


Fig.  253. 


Epithelioma  of  the  U'pper  Lip— Early  Stage.     (After  Sutton. 


Fig.  254. 


Carcinoma  of  the  Upper  Lip.     CA.fter  Senn.) 


CARCINOMATA. 


555 


few  exceptions,  the  disease  if  left  to  itself  involves  the  greater  portion 
of  the  lip  or  destroys  it  altogether,  and  the  chin,  cheek,  and  lower  jaw 
are  successively  implicated.  The  submaxillary  lymphatic  glands  on 
the  affected  side  at  this  time  are  enlarged,  and  become  adherent  to  the 
maxillary  bone,  which  gives  the  appearance  of  malignant  disease  aris- 
ing from  the  periosteum  of  the  jaw. 

The  disease  sometimes  appears  as  a  warty  excrescence,  which  may 
involve  the  entire  lip.     (Fig.  255.) 


Fig.  255 


r 


fT^' 


Epithelioma  of  the  Lower  Lip— "  Warty"  Variety.     (After  Sutton.) 


Occasionally  it  may  occur  that  the  lip  will  be  affected  upon  one 
side,  and  the  lymphatic  glands  of  the  submaxillary  region  upon  the 
other.  No  explanation  of  this  peculiarity  is  yet  forthcoming.  (Sut- 
ton.) 

Sometimes  the  glands  are  affected  upon  both  sides,  but  this  is 
usually  an  expression  of  rapid  extension  of  the  primary  dis.ease  to  the 
opposite  side  of  the  lip,  wath  implication  of  the  mental  and  submental 
tissues,  of  the  most  serious  character,  and  suggests  an  early  termination 
of  the  Hfe  of  the  patient.     In  the  later  stages  of  the  disease,  the  sub- 


556  SURGERY    OF    THE    FACE,    jNIOUTII,    AND    JAWS. 

maxillary  triangles  and  the  neck  become  greatly  enlarged,  food  is  taken 
with  difficulty,  and  the  patient  slowly  dies  from  marasmus,  sepsis,  or 
a  general  infection  and  dissemination  of  the  disease,  or  from  hemor- 
rhage. Metastatic  nodules  are  sometimes  found  in  the  internal  or- 
gans. The  disease  usually  terminates  fatally  in  from  three  to  five 
years,  though  occasionally  it  runs  a  much  shorter  course. 

•  Carcinoma  is  much  more  frequent  in  the  lower  than  in  the  upper 
lip.  It  is  common  in  men,  but  exceedingly  rare  in  women.  Konig's 
statistics  place  the  proportion  of  males  to  females  as  20  to  i.  War- 
ren's reported  cases  make  the  proportion  19.25  to  i,  while  those  of 
Lortets"  show  the  proportion  to  be  y.^  to  i. 

W.  Roger  Williams,  in  a  recent  contribution  to  the  British  Medical 
Journal  regarding  primary  neoplasms  of  the  lip,  states  that  of  13,824 
primary  neoplasms  of  all  kinds,  consecutively  under  treatment  at  St. 
Bartholomew's,  University  College,  Middlesex,  and  St.  Thomas  Hos- 
pitals, during  the  last  sixteen  to  twenty-one  years,  352,  or  2.5  per  cent., 
originated  in  the  lips.  These  included  7297  cancers,  of  which  332  grew 
from  the  lips,  or  4.5  per  cent.  Of  the  352  lip-neoplasms,  340  sprang 
from  the  lower  lip,  thus:  epithelioma,  329  (males  326,  females  3);  papil- 
loma, 7  (males  4,  females  3);  angeioma,  3  (male  i,  females  2);  cystoma, 
I  (male).  Only  12  originated  in  the  upper  lip,  thus:  epithelioma,  3 
(male  i,  females  2);  sarcoma,  4  (males  2,  females  2);  angeioma,  3 
(male  i,  females  2);  papilloma,  i  (female);  fibroma,  i  (male). 

Carcinoma  is  oftener  seen  upon  the  left  side  of  the  lip  than  upon 
the  right.  It  may  also  occur  upon  the  median  line.  (Warren.)  The 
cause  of  the  disease  is  often  ascribed  to  some  form  of  chronic  irritation. 

Irritation  from  the  constant  use  of  tobacco,  and  particularly  of  the 
pipe,  has  been  thought  by  many  to  be  a  prolific  cause  of  carcinoma  of 
the  lip. 

Mason  Warren  ascertained  that  out  of  yy  cases  of  carcinoma  of 
the  lower  lip,  all  but  seven  were  in  the  habit  of  smoking;  out  of  this 
number  four  were  women,  and  three  of  them  were  in  the  habit  of  using 
a  pipe. 

It  is  a  significant  fact  in  the  observation  of  the  writer,  that  the 
side  of  the  lip  most  often  the  seat  of  the  disease  is  the  side  of  the  mouth 
upon  which  the  pipe  has  been  habitually  carried.  It  has  also  been 
observed  that  smokers  who  are  subjects  of  carcinoma  of  the  lower  lip 
have  frequently  been  in  the  habit  of  using  clay  pipes,  the  stems  of  which 
have  not  been  prepared  to  prevent  the  irritation  of  the  lip  so  common 
in  using  new  ones.  J.  C.  Warren  mentions  a  case  of  carcinoma  of  the 
lip  occurring  in  a  woman, — the  only  one  coming  under  his  observa- 
tion,— and  she  was  in  the  habit  of  smoking.  The  carcinoma  in  this 
case  was  in  the  upper  lip.  The  writer  has  seen  one  case  of  the  disease 
in  an  Irish  woman,  seventy  years  old,  an  habitual  smoker,  and  who 


CARCINO:\IATA. 


557 


always  used  a  clay  pipe.     In  this  case  the  neoplasm  was  in  the  lower 

lip  upon  the  left  side.     The  pipe  was  carried  between  the  teeth  upon 

the  left  side,  the  stem  of  which  had  worn  for  itself  a  notch  in  the  upper 

and  lower  teeth,  in  which  it  rested. 

The  writer  has  also  seen  several  cases  of  carcinoma  of  the  lip  in 

men  where  the  evidence  was  unmistakable  that  the  disease  had  started 

in  an  abrasion  or  excoriation  caused  by  the  stem  of  the  pipe  resting 

upon  the  lip. 

Fig.  256. 


Epithelioma  of  the  Lower  Lip  beginning  in  a  Fissure.     (After  Sutton.) 


The  formation  of  the  neoplasm  is  frequently  preceded  by  a  crack 
or  a  fissure  (Fig.  256),  or  an  eczematous  patch  in  the  margin  of  the  lip 
(Senn),  or  by  an  injury.  Out  of  145  patients  suffering  from  carcinoma 
of  the  lip,  Koch  attributed  15  to  traumatisms.     (Senn.) 

Diagnosis. — In  the  diagnosis  of  carcinoma  of  the  lip,  there  is  dan- 
ger of  confounding  eczematous  conditions  with  the  superficial  spread- 
ing form  of  carcinoma  in  its  early  state.  The  exposure  of  the  deeper 
layers  of  the  skin,  the  papillomatous  appearance,  the  raw  surface  and 
serous  transudation  all  tend  to  render  the  diagnosis  somewhat  difficult. 
The  presence  of  an  indurated  condition  of  the  deeper  structures  of  the 
skin  or  of  the  mucous  membrane,  associated  with  these  symptoms, 
marks  the  carcinomatous  character  of  the  growth,  while  the  absence 
of  the  induration  marks  its  eczematous  character.  A  primary  syphil- 
itic sore  might  mislead  in  the  diagnosis,  were  it  not  remembered  that 


558 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


it  develops  very  rapidly,  and  is  associated  at  a  very  early  period  in  its 
history  with  glandular  infection.  The  opposite  of  these  conditions 
marks  even  the  most  rapid  growth  of  carcinoma.  A  secondary  syph- 
ilitic lesion  of  the  lip  usually  originates  in  the  mucous  membrane  of  the 
mouth,  and  infects  the  lip  by  extension.  (Senn.)  Primary  tubercu- 
losis of  the  lip  is  a  very  rare  affection.     It  may  be  distinguished  from 


Fig.  257. 


Carcinoma — Epithelioma  of  Lip.     {A  )     X  50 


carcinoma  by  its  more  diffuse  character  from  the  beginning,  and  the 
absence  of  the  induration  so  characteristic  of  carcinomatous  growths. 
Doubts  as  to  the  character  of  the  tumor  can  be  cleared  up  by  the 
microscopic  character  of  the  tissues,  and  by  inoculation  experiments. 
Figs.  257,  258  show  the  histologic  structure  of  epithelioma  of  the  lip. 

Prognosis. — The  prognosis  is  usually  favorable  in  those  cases  in 
which  an  operation  is  made  in  the  early  stage  of  the  disease — while  it 
is  still  superficial.  But  an  opinion  upon  the  matter  should  be  guarded 
even  here.     Complication  of  the  lymphatic  glands  is  usually  consid- 


CARCIXO.MATA. 


559 


ered  as  an  exceedingly  unfavorable  syniploni,  and  the  utility  of  an 
operation  for  their  removal,  if  much  enlarged,  is  open  to  serious  ques- 
tion. \\'hcn  of  small  size  and  freely  movable,  they  should  be  extir- 
pated, together  with  as  much  of  the  surrounding  tissue  as  may  be 
safely  removed. 

Occasionally  the  operation  for  even  the  superficial  form  of  the  dis- 
ease is  quickly  followed  by  recurrence.  Warren  relates  the  case  of  a 
"physician  who  applied  for  operation  about  three  months  after  the  first 

Fig.  258. 


Inflammatory 
tissue. 


Capsulated  cell. 


Fatty  degenera- 
tion. 


Carcinoma— Epithelioma  of  Lip.     (B.)     X  100. 

appearance  of  the  disease.  There  was  no  return  in  the  lip,  but  a  gland 
under  the  jaw  began  to  enlarge  six  months  later,  and  the  patient  suc- 
cumbed eighteen  months  after  the  first  appearance  of  the  disease." 
Fortunately  such  cases  are  exceptional,  but  there  are  few  surgeons  of 
many  years'  practice  who  have  not  had  like  unfortunate  experiences. 

In  those  cases  in  which  the  glandular  structures  are  involved  to 
any  considerable  extent,  and  the  jaw  has  become  infected,  operations 
are  of  very  little  value. 

Treatment. — Carcinoma  of  the  lip  in  its  early  stages  may  be  readily 


56o 


SURGERY    OF    THE    FACE,    MOUTPI,    AND   JAWS. 


removed  by  a  A'-shaped  excision  of  the  lip.  (Fig.  259. j  When  the  loss 
of  tissue  has  been  comparatively  small,  not  more  than  half  the  width  of 
the  lip,  the  defect  may  be  remedied  by  simply  bringing  the  edges  of  the 
wound  together  and  suturing  them  in  that  position.  This  leaves  at 
first  a  puckered  condition  of  the  mouth  (Fig.  260 j,  but  the  lower  lip 
gradually  elongates,  and  after  a  time  a  fairly  good  lip  results. 

Fig.  259. 


V-SHAPED  Excision  of  the  Lower  Lip  for  Carcinoma.     (After  Esmarch.) 


Fig.  260. 


Operation  Co.mpleted.     (After  Esmarch.) 

Fig.  261. 


Suturing  after  Excision  of  the  entire  Margin  of  the  Lower  Lip  for  Carcinoma. 

(After  Esmarch.) 

Another  method  is  that  of  Celsus.  After  removing  the  tumor  by 
the  V-shaped  incision,  horizontal  incisions  are  carried  out  from  the 
base  (apex  of  the  V)  for  a  sutificient  distance  to  enable  the  wound  to 
approximate  more  easily. 

In  cases  of  superficial  carcinoma  of  the  border  of  the  lip  involving 
only  the  mucous  and  submucous  tissues,  an  incision  mav  be  made  at 


CARCINOMATA. 


561 


one  angle  of  the  mouth,  and  carried  through  the  Hp  to  the  opposite 
oral  angle,  removing  the  entire  margin  of  the  lip.  The  mucous  mem- 
brane is  then  reflected  over  the  surface  of  the  wound,  and  sutured  to 
the  margin  of  the  skin.     (Fig.  261.) 

In  cases  requiring  the  removal  of  more  than  half  of  the  width  of 
the  lip,  it  should  be  done  by  a  curved  incision,  the  convexity  being 
downward.     The  mucous  membrane  may  then  be  lifted  and  sutured 


Langenbeck's  Method  of  Restoring  the  Lower  Lip  after  Excision  for  Carcinoma. 

(After  Langenbeck.) 


Operation  Completed.    (After  Langenbeck.) 

over  the  surface  of  the  wound  to  the  margin  of  the  skin.  This  leaves 
a  semilunar  defect  in  the  border  of  the  lip,  but  in  the  course  of  time  it 
gradually  diminishes.  When  the  entire  lip  has  to  be  excised,  a  new 
lip  must  be  made  by  a  plastic  operation.  Langenbeck  has  devised  a 
method  of  accomplishing  this.  (Fig.  262.)  The  lower  horizontal 
margin  of  the  defect  is  prolonged  on  either  side  by  incisions,  which 
pass  along  the  remainder  of  the  lower  lip,  around  the  angles  of  the 
mouth  and  into  the  upper  lip ;  each  portion  of  the  lip  is  mobilized  and 
drawn  together  by  sutures.     Fig.  263  shows  the  operation  completed. 

37 


562 


SURGERY   OF   THE   FACE,    MOUTH,    AND   JAWS. 


Tlie  objection  to  Langenbeck's  second  method  is  the  fact  that  the 
border  of  the  new  hp  cannot  be  covered  with  mucous  membrane,  and 
that  cicatricial  contraction  takes  place  to  a  certain  extent  during  the 
healing  of  the  wound. 

Hueter's  operation  for  the  restoration  of  the  lower  lip  is  also  a 
valuable  method,  and  is  described  as  follows:  The  margins  of  the  defect 
in  the  lip  are  brought  together  by  sutures,  and  an  incision  is  made  in 

Fig.  264. 


Cheiloplasty.     (After  Bruns.) 

the  cheek  horizontally  outward  from  the  angle  of  the  mouth,  involving 
the  entire  thickness  of  the  cheek;  the  mucous  membrane  on  each  side 
of  the  new  wound  is  reflected  a  little  and  then  united  to  the  skin  by 
sutures. 

Operations  for  the  removal  of  tumors  located  in  the  upper  lip  do 
not  differ  for  partial  excision  from  those  practiced  upon  the  lower  lip. 
In  those  cases  requiring  the  excision  of  the  entire  upper  lip,  the  defect 


Operation  Completed.     (After  Bruns.) 

may  be  cured  by  the  method  devised  by  Bruns,  which  consists  in  fash- 
ioning two  quadrilateral  flaps  out  of  the  entire  thickness  of  the  cheek 
and  upper  lip,  on  each  side  of  the  mouth,  and  turning  them  down  so 
that  their  upper  borders  can  be  sutured  together  in  the  median  line. 
(Fig.  264.)  Finally  the  edges  of  the  wounds  left  upon  each  side  are  to 
be  brought  together  with  sutures,  and  their  size  diminished  as  much  as 
possible.     (Fig.  265.) 


CARCINOMATA.  563 

In  all  operations  upon  the  face  the  utmost  care  should  be  exercised 
to  reduce  to  a  minimum  the  deformities  and  scars  left  by  surgical 
operations  and  accidents.  Plastic  surgery  has  been  brought  to  such 
a  high  degree  of  perfection  that  there  are  few  defects  in  connection 
with  the  human  face  which  cannot  be  restored  with  fairly  good  cos- 
metic and  functional  results. 


CHAPTER    LV. 
CARCINOMATA  (Continued). 

Carcinoma  of  the  Buccal  Mucous  Membrane  and  Jaws. — The  buccal 
mucous  membrane  is  covered  by  pavement  epithelium  several  layers  in 
thickness.  The  superficial  layers  represent  the  squamous  or  flat  epithe- 
lium, and  the  deeper  layers  the  cylindric  or  columnar  variety.  Carcin- 
oma of  the  mouth  has  its  origin,  as  in  the  skin,  either  in  the  stratified 
epithelium  or  in  the  cylindric  epithelial  cells  of  its  glandular  appendages. 

Two  forms  of  carcinoma  are  found  in  the  mucous  membrane  as  in 
the  skin,  viz:  the  superficial  and  the  deep-seated  varieties.  The  only 
differences  between  these  forms  are  those  due  to  peculiarities  in  the 
structural  arrangement  of  the  epithelial  cells,  and  to  the  tissues  being 
constantly  bathed  with  moisture. 

The  superficial  form  of  the  disease  follows  the  clinical  history  of 
the  affection  as  found  in  the  skin,  being  confined  to  the  superficial 
layers  of  the  epithelium,  and  manifesting  no  tendency  to  involve  the 
glandular  structures  of  the  mucous  membrane. 

The  first  manifestation  of  the  deep-seated  variety  of  the  disease  is 
usually  the  formation  of  a  small,  hard  nodule  within  a  tubular  gland  of 
the  mucous  membrane.  The  epithelial  cells  forming  the  center  of  the 
nodule  undergo  fatty  degeneration,  and  finally,  when  ulceration  takes 
place,  the  atheromatous  mass  can  sometimes  be  squeezed  out,  leaving 
a  deep  central  depression  upon  the  surface  of  the  ulcer.  The  base  of 
the  ulcer  is  always  indurated,  while  the  edges  are  raised  above  the  sur- 
rounding surface.  The  ulcer  shows  no  tendency  to  heal,  but,  on  the 
contrary,  spreads  in  all  directions.  Microscopically  the  tumor  pre- 
sents a  tubular  structure,  the  tubules  being  lined  with  columnar  epi- 
thelial cells.  This  form  of  the  disease  is  most  frequently  located  in  the 
mucous  membrane  of  the  cheek,  but  it  may  originate  in  the  gums,  the 
soft  palate,  the  tonsils,  and  the  pharynx.  The  disease  often  starts  near 
the  angle  of  the  mouth,  and  extends  backward  upon  the  cheek;  or  it 
begins  in  the  gingivo-buccal  fold,  and  occasionally  in  the  center  of  the 
cheek  upon  a  line  indicated  by  the  occlusion  of  the  upper  and  lower 
teeth.  The  disease  is  rarely  seen  at  the  angle  of  the  mouth  or  in  the 
upper  lip,  which  is  explained  by  the  fact  that  the  mucous  glands  are  less 
564 


CARCINOMATA.  5^5 

numerous  in  these  locations  than  in  other  portions  of  the  oral  mucous 
membrane. 

Carcinoma  of  the  oral  mucous  membrane  has  been  thought  by 
some  observers  to  be  due  to  the  irritating  effects  of  tobacco,  as  produced 
by  smoking,  but  as  there  are  no  statistics  presented  to  corroborate  the 
statement,  it  is  presented  merely  as  an  opinion.  Carcinoma  of  the 
mucous  membrane  of  the  cheek  is  sometimes  preceded  by  the  ap- 
pearance of  a  patch  of  "leucoma"  or  leucoplakia,— a  chronic  super- 
ficial inflammation  of  the  mucous  membrane  or  the  tongue,  charac- 
terized by  the  presence  of  pearly-white  or  bluish-white  patches  upon 
the  surface  of  the  gums,  mucous  membrane,  or  tongue.  The  affection 
is  rare  in  women  or  in  individuals  under  twenty  years  of  age.  It  is  due 
to  some  chronic  form  of  irritation,  such  as  the  smoking  of  a  pipe,  or  the 
wearing  of  artificial  teeth.     Wallenberg  believes  it  is  caused  most  fre- 

FiG.  266. 


First  bicuspid. 


Mixed  Carcinoma  of  the  Inferior  Maxilla.     (A.) 


quently  by  the  irritation  produced  by  the  volatile  and  empyreumatic 
oils  of  tobacco.  (Warren.)  The  writer  has  seen  several  cases  of  leuco- 
plakia in  men,  and  one  in  a  woman.  (See  chapter  on  Leucoplakia.) 
In  one  of  these  cases  the  affection  was  upon  the  dorsum  of  the  tongue 
near  the  center,  the  patch  being  the  size  of  a  quarter-dollar  piece. 
This  gentleman  was  forty  years  old,  and  a  great  smoker  of  cigars. 
It  had  caused  no  inconvenience,  although  it  had  been  there  for  sev- 
eral years.  In  another  case  the  disease  was  located  in  the  left  gingivo- 
buccal  fold,  but  principally  upon  the  gum,  in  a  man  past  fifty  years  of 
age.  The  disease  had  been  noticed  for  several  years,  and  for  more 
than  a  year  past  had  been  very  troublesome,  causing  pain  and  smarting 
when  acids,  salt,  or  anything  of  pungent  flavor  came  in  contact  with  it. 
Operation  was  advised,  but  declined.  Soon  after  this  it  took  on  ma- 
lignant symptoms,  extending  to  the  superior  maxillary  bone  and  the 
whole  side  of  the  cheek.  Three  years  afterward  he  died  from  exten- 
sion of  the  malignant  disease  to  the  throat  and  lymphatic  glands  of  the 
neck.  The  third  case  was  similar  to  the  second  in  its  location.  This 
patient  was  a  physician  forty-five  years  of  age,  and  appreciated  the 


566 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


danger  of  procrastination  in  an  affection  of  this  character.  The  pres- 
ence of  the  disease  was  discovered  by  accident  during  an  examination 
of  his  teeth.  It  was  evidently  in  its  early  stage  of  development,  as  its 
presence  had  never  been  recognized  by  the  patient.  He  demanded  an 
immediate  operation,  and  the  diseased  tissue  was  removed  down  to  the 
bone.    Eight  years  afterward  there  had  been  no  recurrence. 

Fig.  267. 


WOK^B^- 


Epithelium. 


Carcinoma— Mixed— OF  Inferior  Maxilla.     (B.)     Fibrous  Portion.    X  7°- 


The  fact  that  carcinoma  of  the  cheek  frequently  appears  along  the 
line  of  the  occlusal  surfaces  of  the  superior  and  inferior  molars,  oppo- 
site decayed  or  roughened  buccal  surfaces  of  the  teeth,  or  upon  the 
tongue  or  gums,  irritated  by  the  same  means,  leaves  no  doubt  that 
these  agencies  are  prolific  exciting  causes  of  the  disease. 

Carcinoma  may  appear  in  the  superior  or  inferior  gum,  but  it  is 


CARCINOMATA. 


567 


most  frequently  seen  in  the  mucous  membrane  covering  the  lower 
alveolar  process.  The  disease  usually  arises  in  connection  with  a  cari- 
ous tooth  in  which  the  cavity  of  decay  has  extended  beneath  the  mar- 
o-in  of  the  ?um,  leaving  a  sharp  or  jagged  edge;  or  in  relation  with  a 
devitalized  ^and  carious  tooth,  the  crown  of  which  has  been  lost,  leav- 
ing the  root  with  rough  margins  which  irritate  the  gum. 

Fig.  268. 


Carcinoma— Mixed— OF  Inferior  Maxilla.     (C.)    X  70- 

The  affection  in  this  location  is  characterized  by  an  exceedingly 
rapid  progression.  The  bone  is  infected  in  a  very  short  space  of  time, 
and  this  condition  is  often  mistaken  for  the  primary  affection,  ihe 
disease  as  it  progresses  in  the  lower  jaw  has  a  tendency  to  spread  m 
one  direction  toward  the  cheek,  and  in  the  other  toward  the  tongue. 
Figs   266,  267,  268,  269  are  photographs  of  a  mixed  carcinoma  of  the 


568 


SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 


inferior  maxilla  and  its  histologic  structure.  When  located  in  the  su- 
perior maxilla  the  alveolar  process  is  quickly  eroded,  and  the  antrum 
is  invaded,  leaving  a  foul  ulcerating  cavity,  which  discharges  an  of- 
fensive pus.  The  erosion  of  the  bone  as  it  takes  place  in  either  maxilla 
causes  loosening  and  exfoliation  of  the  teeth  in  the  infected  region. 

Fig.  269. 


Carcinoma— Mixed— OF  Inferior  Maxilla.    (D.) 


Carcinoma  of  the  Antrum. — Some  of  the  most  distressing  cases 
of  carcinoma  coming  under  the  observation  of  the  writer  have  been 
those  which  involved  the  antrum  of  Highmore,  either  by  extension 
from  the  mouth,  or  in  which  the  disease  was  primarily  located  in  this 
sinus.  The  latter  form  of  the  disease  occurs  in  individuals  past  mid- 
dle life.     The  first  symptom  complained  of  is  pain  in  the  jaw,  for 


CARCINOMATA.  569 

which  no  adequate  cause  can  be  assigned.  (Sutton.)  Pain  is  some- 
times entirely  absent.  Later  there  is  observed  a  sHght  fullness  in  the 
infra-orbital  region,  with  perhaps  edema  of  the  lower  eyelid,  occasion- 
ally a  mild  degree  of  exophthalmos;  the  skin  becomes  discolored,  and 
later  a  carcinomatous  ulcer  breaks  through  the  skin  of  the  cheek  near 
the  inner  canthus  of  the  eye,  or  into  the  mouth  through  the  alveolus 
of  a  recently  extracted  tooth.  Inspection  of  the  mouth  will  also  reveal 
extensive  erosion  of  the  palate  process,  and  bulging  of  the  roof  of  the 
mouth  upon  the  affected  side.  If  the  case  is  operated  upon  at  this 
period,  it  will  be  found,  upon  reflecting  the  cheek,  that  the  disease  has 
usually  made  such  extended  inroads  upon  the  surrounding  tissues  as 
to  have  involved  not  only  the  palate  process,  but  all  of  the  bony  walls 
of  the  antrum,  penetrated  to  the  muscles  of  the  cheek,  involving  the 
skin,  and  implicating  the  contents  of  the  orbit,  making  it  necessary  to 
remove  the  entire  maxillary  bone  of  the  affected  side,  together  with 
the  infected  tissue  of  the  cheek  and  the  contents  of  the  orbit,  leaving 
a  yawning  chasm  which  cannot  be  closed  by  plastic  operation.  The 
disease  is  very  fatal,  and  life  is  rarely  prolonged  beyond  a  few  months 
at  most,  but  during  that  time  the  patient  is  spared  much  sufifering  and 
discomfort  as  a  consequence  of  the  operation. 

Regional  infection  of  the  lymphatic  glands  is  an  early  and  conspic- 
uous feature  of  the  disease  when  it  involves  the  maxillary  bones.  Sut- 
ton calls  attention  to  the  fact  that  the  infected  lymph  glands  of  the  neck 
may  attain  an  extraordinary  size,  while  the  ulcer  upon  the  gum  may 
be  very  small,  not  exceeding  one  cm.  in  diameter,  thus  tending  to  mis- 
lead the  surgeon  in  his  diagnosis.  He  further  suggests  that  rapid- 
growing  glandular  enlargements  located  in  the  neck  in  persons  past 
middle  life  should  call  for  a  careful  examination  by  the  surgeon  "of  the 
mouth  and  fauces,  for  small  inconspicuous  epitheliomatous  ulcers,  and 
with  every  care  they  sometimes  escape  detection  during  life." 

Carcinoma  of  the  mouth  affecting  the  mucous  membrane  of  the 
cheeks  and  gum,  and  involving  the  superior  maxillary  bones,  is  an 
exceedingly  rapid  and  fatal  form  of  the  disease,  the  average  duration 
of  life  being  about  eighteen  months.  As  a  rule,  these  growths  resent 
surgical  interference.  The  insidious  character  of  the  tumor  is  such 
that  it  has  usually  passed  the  time  when  radical  measures  are  available 
before  its  true  nature  has  been  discovered.  Excision  of  the  growth 
has  almost  always  been  followed  by  recurrence,  for  the  reasons  just 
mentioned.  There  would  seem,  however,  to  be  hope  of  a  permanent 
cure  of  the  disease  if  it  could  be  removed  before  regional  infection  had 
taken  place. 

Treatment. — Surgical  operations  for  carcinoma  of  the  mouth,  to  be 
of  real  value,  must  be  bold,  and  at  the  same  time  most  painstaking. 
There  is  perhaps  no  affection  with  which  these  qualities  of  an  operation 


570  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

are  more  imperatively  demanded.  Timidity  or  carelessness  upon  the 
part  of  the  operator  will  result  not  only  in  a  damaged  reputation,  but 
in  what  is  of  infinitely  more  serious  consequence  to  the  patient, — a 
quick  recurrence  of  the  disease.  Radical  operations  for  carcinoma  of 
the  mouth,  particularly  in  those  cases  affecting  the  maxillary  bones, 
will  require  external  incisions.  Operations  conducted  through  the 
mouth  for  so  grave  an  affection  are  of  little  practical  benefit,  as  it  is 
impossible  to  thoroughly  trace  the  ramifications  of  the  disease,  or  by 
any  possibility  remove  infected  submaxillary  glands  through  this 
cavity. 

The  writer  had  one  unfortunate  experience  in  his  early  practice 
in  attempting  to  remove  such  a  growth  through  the  mouth.  Thor- 
ough removal  of  the  diseased  tissue  was  impossible,  and  the  patient's 
condition  three  months  after  the  operation  was  worse  than  before. 
The  surgical  interference,  on  account  of  the  imperfect  removal  of  the 
carcinomatous  tissue,  and  the  irritation  incident  to  the  operation, 
seemed  to  stimulate  the  growth  to  most  active  cell-proliferation.  Four 
months  after  the  operation  the  patient  died. 

The  incisions  should  always  be  made  with  reference  to  the  least 
possible  amount  of  disfigurement.  When  operating  upon  the  upper 
maxilla,  the  incisions  should  follow  the  natural  lines  of  the  face  as  far 
as  possible;  in  operations  upon  the  lower  jaw  the  lines  of  incision  can 
be  hidden  in  large  part  beneath  the  jaw.  The  extent  and  character  of 
the  particular  operation  in  each  individual  case  will  be  indicated  by  the 
location  of  the  neoplasm  and  the  extent  of  the  infection.  Partial  ex- 
cisions of  the  superior  maxillary  bone  may  be  done  by  the  Nelaton 
operation  or  that  of  Guerin.  Partial  excision  of  the  inferior  maxilla 
may  be  accomplished  by  incisions  passing  through  the  median  line  of 
the  lip  and  chin,  and  carried  backward  to  the  angle  of  the  jaw  beneath 
the  lower  border  of  the  bone. 


CHAPTER    LVL 

CARCIXOMATA  (Continued). 

Carcinoma  of  the  Pharynx. — Primary  carcinoma  of  the  pharynx 
is  a  rare  affection.  AA'hen  the  disease  occurs  in  this  location  it  evinces 
a  tendency  to  rapid  progress  and  wide  extension.  It  has  been  known  to 
involve  in  a  short  space  of  time  the  tonsils,  palate,  larynx,  and  oesopha- 
gus. Involvement  of  the  pharynx  from  carcinomatous  growths  having 
their  primary  origin  in  the  tonsils  or  the  oesophagus  are  of  more  com- 
mon occurrence. 

Carcinoma  of  the  Palate  and  Uvula. — The  primary  form  of  carcin- 
oma in  either  the  palate  or  the  uvula  is  generally  considered  as  a  rare 
affection.  A  few  cases  are  on  record  in  which  the  disease  had  its 
primary  origin  in  one  or  the  other  of  these  organs,  but  the  more 
common  history  is  for  the  disease  to  appear  as  an  extension  from  cancer 
of  the  tonsil  or  of  the  antrum  of  Highmore.  The  most  common  varie- 
ties of  carcinoma  in  the  palate  and  uvula  are  the  medullary  and  the 
epithelial,  the  latter  being  oftenest  found.  In  the  early  stages  of  the 
disease  it  is  liable  to  be  confounded  with  the  secondary  manifestations 
of  syphilis.  Later  it  gives  rise  to  ulceration  and  hemorrhage,  and 
eventually  to  enlargement  of  neighboring  lymphatic  glands  and  metas- 
tasis. 

Symptoms. — Carcinoma  of  the  pharynx,  palate,  and  uvula  are  not 
often  recognized  until  the  tumor  has  reached  a  considerable  size  and 
the  patient  seeks  advice  on  account  of  impeded  deglutition,  articulation, 
and  respiration.  Accompanying  these  symptoms  are  hypersecretion 
from  the  mucous  and  salivary  glands  and  expectoration.  These  often 
become  exceedingly  troublesome.  When  ulceration  takes  place  deglu- 
tition and  speech  are  rendered  painful.  In  the  later  stages  of  the 
disease,  deglutition  sometimes  becomes  impossible  from  extension  of  the 
tumor  to  the  oesophagus  and  the  patient  dies  from  starvation,  or  the 
size  and  location  of  the  growth  may  cause  distressing  dyspnea,  ending 
in  suft'ocation. 

The  prognosis  in  carcinoma  of  the  pharynx  is  always  grave,  as  the 
location  of  the  neoplasm  is  usually  such  as  to  preclude  an  operation 
for  its  removal.  In  carcinoma  of  the  palate  and  uvula  the  prognosis  is 
somewhat  better  from  the  fact  that  in  the  early  stages  of  the  disease  the 
tumor  may  be  successfully  removed  by  an  operation. 

571 


572  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

Treatment. — The  treatment  of  carcinoma  of  the  pharynx  by  sur- 
gical procedure  is  rarely  undertaken  except  in  its  very  earliest  stages, 
on  account  of  the  difficulties  in  the  way  of  an  operation  and  the  attend- 
ant dangers  from  hemorrhage.  Inoculations  with  the  streptococcus 
prodigiosus  at  one  time  gave  hope  of  being  a  curative  measure,  but  this 
hope  has  not  been  realized  in  the  treatment  of  carcinomatous  growths, 
although  several  cases  have  been  reported  of  successful  treatment  of  in- 
operable sarcomas  by  this  means.  Very  little,  however,  can  be  done  in 
the  treatment  of  carcinoma  of  the  pharynx  except  to  relieve  the  suffer- 
ing of  the  patient  by  palliative  measures  until  death  supervenes. 

In  the  treatment  of  carcinoma  of  the  palate  and  of  the  uvula, 
operative  procedures  are  sometimes  successful,  provided  thorough 
extirpation  of  the  neoplasm  has  been  practiced  in  the  early  stages  of 
the  disease.  In  the  later  stages,  when  the  surrounding  structures  have 
become  involved,  and  the  neighboring  lymphatic  glands  are  infected, 
surgical  interference  is  contra-indicated,  except  to  remove  sloughing 
tissue  and  render  the  parts  as  cleanly  as  the  circumstances  will  permit. 

An  early  operation  which  has  proved  to  be  curative  may  leave  a 
somewhat  serious  deformity  by  the  removal  of  the  velum  palati  with 
the  consequent  loss  of  articulate  speech.    The  deformity  may  be  cor- 
rected and  the  speech  restored  by  the  introduction  of  an  artificial  velum 
made  after  the  method  of  Kingsley. 

Carcinoma  of  the  Tongue. — According  to  Butlin,  carcinoma  of 
the  tongue  is  confined  to  the  squamous-celled  variety,  and  he  refutes 
the  statement  that  the  tongue  is  sometimes  the  seat  of  hard  and  soft 
carcinoma.  Fig.  270  shows  a  vertical  section  of  a  circumvallate  papilla 
of  the  human  tongue. 

Carcinoma  of  the  tongue  is  usually  located  upon  the  side  or  the 
dorsum,  usually  near  the  tip.  The  anterior  half  is  much  more  fre- 
quently the  seat  of  the  disease  than  the  posterior  half,  while  it  may  be 
stated  generally  that  the  disease  is  usually  located  in  some  spot  in  its 
anterior  two-thirds,  the  edges  being  more  subject  to  the  disease  than 
either  the  dorsum  or  the  under  side.  (Butlin.)  The  disease  is  always 
even  when  upon  the  dorsum,  distinctly  located  either  upon  one  side  or 
the  other  of  the  median  line,  but  so  far  as  statistics  go,  they  do  not 
show  any  distinct  preference  of  the  disease  for  one  side  over  the  other. 

The  disease  may  make  its  first  appearance  either  as  a  blister,  an 
excoriation,  an  ulcer,  a  fissure,  a  pimple  or  tiny  tubercle,  a  warty 
growth,  or  a  nodule  (Butlin)  upon  the  surface  or  within  the  substance 
of  the  tongue.  In  the  early  stages  of  the  disease  the  microscope  shows 
that  the  tumor  retains  the  papillary  structure  of  the  tongue  upon  its 
surface.  But  later,  after  ulceration  becomes  more  extensive,  infiltra- 
tion from  the  surface  results  in  the  production  of  epithelial  prolonga- 
tions and  the  formation  of  epithelial  "cell-nests"  within  the  vascular 
connective-tissue  stroma  in  typical  concentric  layers.     (Fig.  271.) 


CARCINOMATA. 


573 


Causes. — The  most  frequent  exciting  causes  of  the  disease  are 
chronic  irritation,  from  mechanical  agencies, — rough  or  carious  teeth, 
ill-fitting  dental  plates, — and  the  irritating  influences  of  smoking 
tobacco.  Besides  these  forms  of  irritation  may  be  mentioned  certain 
chronic  inflammatory  affections  of  the  mucous  membrane  which  pre- 
cede the  formation  of  cancerous  growths  in  the  tongue,  viz:  leuco- 
plakia,  ichthyosis,  psoriasis,  and  syphilis. 

Symptoms  and  Diagnosis. — The  disease  usually  runs  a  rapid  course, 
the  lymphatic  glands  of  the  neck  soon  become  infiltrated,  and  death 
svipervenes  in  from  one  to  two  years. 


Fig.  270. 


Vertical  Section  of  Circumvallate  Papilla  of  Human  Tongue.     (T.  Charters  White.) 

X  100. 


Pain  in  carcinoma  of  the  tongue  is  often  quite  sharp  and  severe,  of 
stinging  character,  and  sometimes  reflected  to  the  ear.  As  the  disease 
advances,  speech  and  deglutition  become  more  and  more  embarrassed. 
Salivation  is  also  a  prominent  symptom.  The  surface  of  the  ulcer  is 
sometimes  covered  with  papillary  growths,  sometimes  with  sloughing, 
gangrenous  shreds  of  connective  tissue.  The  indurated  character  of 
the  cancerous  growths  of  both  base  and  margins  remains  throughout 
the  course  of  the  disease. 

The  disease  is  more  common  in  men  than  in  women.  Sutton 
places  the  proportion  as  3  to  i ;  Senn,  7  to  i ;  Butlin  nearly  6  to  i,  and 
Barker,  6.35  to  i.  The  disease  is  pre-eminently  one  of  past  middle  life, 
being  most  frequent  after  the  fortieth  year.     It  has  been  recognized  in 


574 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


patients  as  young  as  twenty-five,  and  as  old  as  seventy-five  years;  the 
largest  number  affected  being  between  the  ages  of  forty  and  sixty,  the 
largest  proportion  between  forty-five  and  fifty.     (Sutton.) 

The  diseases  which  are  most  likely  tO  be  confounded  with  carcin- 
oma are  syphilitic  indurations  and  sores,  tubercular  nodules  and  ulcera- 
tions, warty  tumors,  traumatic  ulcers,  fissures,  and  actinomycosis. 
Syphilitic  indurations — gummata^ — of  the  tongue  may  be  differentiated 

Fig.  2/1. 


'^J^i!'^^"'^^ 


Epithelioma  of  the  Tongue.     (T.  Charters  White.)     X  loo. 


by  the  presence  of  other  syphilitic  lesions  of  the  tongue  or  other  por- 
tions of  the  oral  cavity  or  of  the  body.  Tubercular  disease  of  the 
tongue  is  rarely  seen  in  other  persons  than  those  suffering  from 
pulmonary  tuberculosis.  A  tubercular  ulcer  does  not  possess  the  in- 
durated base  and  margins  characteristic  of  carcinoma,  and  its  surface 
is  covered  with  fungous  granulations.  Actinomycosis  is  an  exceed- 
ingly rare  disease  in  man.  The  microscope  is  the  only  means  of  posi- 
tive diagnosis. 

Prognosis. — The  prognosis  of  carcinoma  of  the  tongue  is  always 


CARCINOMATA.  575 

unfavorable.     When  the  disease  is  left  to  itself,  it  usually  terminates 
the  life  of  the  patient  in  from  one  to  two  years. 

Operation  in  the  cases  which  are  unmistakably  carcinoma  tends 
to  relieve  pain  and  distress,  and  prolongs  life  for  a  short  time;  but  the 
end  is  nearly  always  recurrence  in  the  remaining  portion  of  the  tongue, 
or  secondary  disease  in  the  lymphatic  glands  of  the  neck.  The  pro- 
longation of  life  by  an  operation  has  been  variously  estimated  at  from 
five  to  eight  months.  The  operation  itself  is  always  a  dangerous  one; 
hemorrhage  and  septic  pulmonary  conditions  being  the  chief  causes  of 
fatalities  from  the  operation. 

Treatment. — Radical  operations  for  the  treatment  of  carcinoma  of 
the  tongue  are  to  be  preferred  to  treatment  by  caustics.  The  applica- 
tion of  caustics,  as  a  rule,  seems  only  to  stimulate  the  proliferation  of 
the  "cancer-cells,"  and  renders  the  growth  of  the  tumor  more  rapid 
and  malignant. 

As  a  preliminary  to  all  operations  upon  the  tongue,  Billroth  re- 
commended a  careful  disinfection  of  the  entire  cavity  of  the  mouth. 
This  process  to  be  of  real  value  will  require  a  painstaking  cleansing  of 
the  teeth  by  the  removal  of  all  salivary  deposits  and  alimentary  debris, 
followed  by  the  free  use  of  antiseptic  solutions. 

To  draw  the  tongue  forward,  and  to  hold  it  in  position  during  the 
operation,  a  stout  ligature  should  be  passed  through  the  tip  at  the 
median  line,  and  the  ends  tied. 

Hemorrhage  is  often  very  troublesome  in  operations  requiring 
partial  or  complete  excision  of  the  tongue;  to  guard  against  accidents 
from  this  cause  many  surgeons  are  in  the  habit  of  ligating  one  or  both 
lingual  arteries,  or  a  temporary  ligature  may  be  so  placed  upon  the 
tongue  as  to  entirely  prevent  the  bleeding  during  excision  of  any  por- 
tion of  the  anterior  half,  or  even  two-thirds  of  the  organ.  This  is  ac- 
complished by  passing  a  well-curved  needle  armed  with  a  strong  dou- 
ble silk  ligature,  through  the  middle  of  the  tongue,  as  near  its  base  as 
possible.  The  ligature  is  then  cut  close  to  the  eye  of  the  needle,  and 
each  thread  tied  separately,  one  upon  each  side  if  the  whole  tongue  is 
to  be  rendered  bloodless.  (Figs.  272  and  273.)  If  but  one  half  is 
to  be  excised,  the  ligature  need  be  tied  only  upon  the  side  to  be  re- 
moved. The  ligatures  may  be  left  long  enough  to  extend  outside  the 
mouth,  and  the  ends  tied,  as  they  are  useful  in  drawing  forward  the  root 
of  the  tongue  and  giving  a  good  view  of  that  portion  of  the  organ, 
which  is  so  necessary  when  the  disease  is  located  near  its  base. 

Senn  advises  the  use  of  an  elastic  ligature  in  the  form  of  a  piece  of 
small  drainage  tube,  about  twelve  inches  long,  doubled  and  passed 
through  an  opening  in  the  base  of  the  tongue  at  the  median  line,  made 
by  tunneling  the  tissues  with  a  pair  of  hemostatic  forceps.  The  tube 
is  to  be  cut  in  the  center,  and  each  piece  tied  at  opposite  sides  of  the 


576 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


tongue  sufficiently  tight  to  arrest  all  hemorrhage.     The  jaws  must  also 
be  opened  to  their  fullest  extent  by  means  of  a  suitable  mouth-gag. 

The  operation  for  partial  or  complete  excision  of  the  tongue  may 
be  done  by  several  methods.  On  account  of  the  hemorrhage  which 
so  often  follows  the  use  of  the  knife  or  scissors,  the  ecraseur  (Fig.  274) 
or  the  galvano-cautery  wire  were  formerly  substituted  by  many  sur- 

FiG.  272. 


Temporary  Constriction  of  One-half  of  the  Tongue.     (After  Esmarch  and  Kowalzig.) 

Fig.  273. 


Temporary  Constriction  of  Whole  Tongue  at  its  Base.     (After  Esmarch  and  Kowalzig.) 


geons  for  this  operation,  but  of  late  the  great  majority  have  gone  back 
to  the  use  of  the  knife  or  scissors,  as  the  other  means  did  not  always 
prevent  hemorrhage  when  the  excision  took  place  near  the  base  of  the 
tongue. 

Small  carcinomatous  tumors  may  be  readily  removed  through  the 
mouth  by  a  V-shaped  incision  made  by  a  blunt-pointed  bistoury  or 
scissors,  the  portion  to  be  removed  having  been  previously  seized  with 


CARCINOMATA. 


577 


double-pronged  forceps,  and  the  tongue  drawn  well  forward.  All 
bleeding  vessels  are  then  secured,  and  the  edges  of  the  wound  brought 
together  with  sutures.     (Figs.  275,  276,  277,  278.) 

Operation  through  the  mouth  is  applicable  for  the  removal  of  the 
anterior  third  or  half  of  the  tongue.  When  a  lateral  half  is  to  be  re- 
moved it  may  be  accomplished  in  the  following  manner:  Two  stout 

Fig.  274. 


Chassaignac's  Chain  Ecraseur. 


Fig.  275. 


Removal  of  Tumor  of  the  Tongue —Insertion  of  Traction-Suture.     (After  Esmarch.) 


ligatures  are  passed  through  the  tip  of  the  tongue,  one  on  each  side  of 
the  median  line,  which  are  to  be  used  to  draw  the  organ  forward;  the 
tip  is  then  raised,  the  frenum  cut  with  scissors,  and  the  tongue  dis- 
sected from  the  floor  of  the  mouth  as  far  back  as  is  necessary.  The 
tongue  is  then  split  upon  the  median  line,  from  before  backw^ard,  freed 
from  the  underlying  parts  by  tearing  with  the  finger,  and  the  posterior 
section  made  with  the  knife  or  scissors. 

38 


578 


SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 


Whitehead  removes  the  entire  tongue  through  the  mouth,  but 
does  not  practice  preliminary  Hgation  of  the  Hngual  arteries;  these  ves- 
sels he  secures  as  they  are  divided. 

Langenbeck  secures  access  to  the  base  of  the  tongue  by  an  inci- 
sion made  at  the  angle  of  the  mouth  and  carried  downward  to  the  thy- 
roid cartilage;  through  this  incision  any  infected  lymphatic  glands,  or 


Fig.  276. 


Excis:oN  OF  Tumor.    (After  Esmarch.) 

Fig.  2^^. 


Tying  ok  First  Suture.     (After  Esmarch.) 


Fig.  278. 


Operation  Completed.    (After  Esmarch.) 

the  submaxillary,  may  be  removed.  Division  of  the  digastric  and 
hypoglossus  muscles  is  then  made,  and  the  lingual  artery  tied.  The 
jaw  is  next  divided  at  the  line  of  the  incision,  and  the  segments  sepa- 
rated, after  which  the  mucous  membrane  is  severed  from  the  inner  sur- 
face of  the  posterior  segment  as  far  back  as  the  anterior  pillar  of  the 
fauces.     Through  this  opening  it  is  not  only  possible  to  reach  the  base 


CARCINOiMATA. 


579 


of  the  tongue,  and  amputate  it  at  this  point,  but  also  to  reach  the  tonsil 
and  the  soft  palate,  and  remove  them  when  necessary.     (Fig.  279.) 

Billroth  modified  this  operation  by  dividing  the  soft  tissues  and  the 
jaw  at  both  angles  of  the  mouth,  and  turning  down  the  central  segment. 

Regnoli  devised  a  method  in  1838,  later  modified  by  Billroth, 
which  provides  free  access  to  the  base  of  the  tongue  without  division  of 

Fig.  279. 


Amputation  of  the  Tonguk  by  Langenbeck's  Method. 


Fig.  280. 


Amputatio 


N  OF  THE  Tongue  according  to  Regnoli-Billroth. 


the  lower  jaw.  An  incision  is  made  along  the  inner  surface  of  the 
lower  border  of  the  jaw  from  angle  to  angle,  and  the  cavity  of  the 
mouth  opened  from  beneath.  The  tongue  is  then  seized  and  drawn 
down  and  forward,  until  its  base  is  within  easy  reach.  (Fig.  280.) 
This  operation  has  the  advantage  of  affording  free  access  to  infected 
glands,  the  establishment  of  adequate  drainage,  and  of  allowing  the 
best  antiseptic  treatment  of  the  wound. 

Kocher's  method  is  to  make  an  incision  "from  the  under  border  of 


580  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

the  lower  jaw  near  the  symphysis,  in  the  direction  of  the  anterior  belly 
of  the  digastric  muscle  to  the  hyoid  bone ;  thence  backward  to  the  an- 
terior border  of  the  sterno-cleido-mastoid  muscle;  then  upward  along 
it  to  or  above  the  angle  of  the  jaw."  The  flap  is  then  raised  as  far  as 
the  lower  border  of  the  jaw,  and  an  incision  made  through  the  floor  of 
the  mouth  as  close  to  the  bone  as  possible,  and  through  this  opening 
the  tongue  can  be  drawn  down  and  amputated.  (Fig.  281.)  Kocher's 
operation  requires  preliminary  tracheotomy.  The  advantages  of  this 
operation  are  the  facility  with  which  infected  glands  may  be  reached 
and  removed  and  the  lingual  artery  tied.  It  also  permits  the  pack- 
ing of  the  fauces  with  sponges  or  gauze,  thus  preventing  the  entrance 
of  blood  into  the  trachea,  and  facilitates  antiseptic  treatment  of  the 
mouth.  The  tracheotomy  tube  should  remain  for  several  days,  the 
patient  to  be  fed  through  an  oesophageal  tube. 

Fig.  281. 


Kocher's  Incision  in  Amputation  of  the  Tongue. 

Senn  recommends  the  passing  of  two  traction  sutures  through  the 
base  of  the  tongue,  which  are  then  brought  out  of  the  mouth,  in  cases 
of  amputation  of  the  entire  organ,  and  are  used  afterward  as  a  means  of 
fixing  the  stump  for  a  few  days  in  its  proper  position.  He  thinks  this 
is  an  exceedingly  important  precaution.  The  after-treatment  consists 
of  establishing  drainage  and  as  thorough  antiseptic  conditions  as  the 
nature  of  the  case  will  permit.  A  saturated  boric  acid  solution,  or  the 
Thiersch  solution,  are  the  most  valuable  antiseptics  for  use  in  these 
cases. 

Carcinoma  of  the  Tonsils. — Carcinoma  of  the  tonsils  is  by  no 
means  a  common  afTection.  It  is  observed  most  frequently  in  male 
subjects  after  middle  life.  Cohen  says  all  the  cases  seen  by  him  were  in 
male  subjects.  The  epithelial  and  medullary  varieties  of  the  disease 
are  both  seen  in  this  location.  The  medullary  variety  is  the  most  com- 
mon and  is  also  the  most  rapid  in  its  growth  and   extension.     The 


CARCINOMATA. 


581 


affection  is  sometimes  primary,  but  more  often  it  appears  as  an  exten- 
sion from  the  base  of  the  tongue,  the  palate,  or  the  pharynx. 

Primary  carcinoma  of  the  tonsil  is  usually  confined  to  this  organ 
for  a  considerable  time,  and  during  its  early  stages  cannot  be  distin- 
guished from  hypertrophy,  except  by  the  absence  of  a  previous  history 
of  tonsillitis,  by  the  age  of  the  patient,  and  by  its  unilateral  manifesta- 
tion. Later  the  surrounding  tissues  become  infiltrated,  and  the  sub- 
maxillary glands  and  the  cervical  lymphatics  become  enlarged. 

Symptoms.— As  the  tumor  increases  in  size  the  patient  will  com- 
plain of  pains  in  the  ear,  head,  throat,  and  neck,  sometimes  extending 
to  the  shoulder  and  arm,  which  are  produced  by  the  pressure  of  the 
neoplasm  upon  nerves  supplying  these  parts.  With  the  extension  of 
the  disease  there  will  develop  salivation,  dysphagia,  difficult  and  mdis- 
tinct  articulation,  progressive  emaciation,  accompanied  by  softenmg  and 
ulceration  in  the  oldest  portions  of  the  tumor,  with  frequent  and  some- 
times severe  hemorrhage,  the  latter  not  infrequently  proving  fatal  from 
involvement  of  the  internal  carotid  artery.  The  disease  sometimes 
extends  to  the  base  of  the  tongue,  the  floor  of  the  mouth,  the  epiglottis 
and  pharynx,  the  palate  and  the  palatine  folds. 

In  the  early  stages  of  medullary  carcinoma  there  is  some  difficulty 
in  making  a  diagnosis,  but  in  the  later  stages  when  ulceration  takes 
place  and  the  fungus-appearing  growths  are  developed,  the  diagnosis 

becomes  plain. 

Epithelial  carcinoma  during  the  early  stages  of  ulceration  is  some- 
times mistaken  for  syphilis. 

Carcinoma  of  the  tonsils  the  result  of  extension  from  the  base  of 
the  tongue  or  from  the  pharynx,  may  eventually  involve  the  palate,  the 
larynx,  and  the  oesophagus.  The  disease  may  result  also  from  metastasis 
from  carcinoma  of  internal  glandular  structures. 

Prognosis.— The  prognosis  of  carcinoma  of  the  tonsils  is  always 
very  grave.  The  disease,  as  a  rule,  progresses  very  rapidly,  and  when 
occurring  in  the  tonsil  as  a  primary  growth  it  may  in  a  period  of  two  or 
three  months  extend  to  the  pillars  of  the  fauces,  the  soft  palate,  the 
base  of  the  tongue,  and  the  pharynx.  Death  may  take  place  either  from 
asphyxia,  asthenia,  or  hemorrhage. 

Tr^a^m^n^.— Carcinoma  of  the  tonsil,  if  discovered  in  its  earliest 
stages  and  while  yet  confined  to  the  gland,  may  be  successfully  removed 
through  the  mouth,  but  the  entire  gland  must  be  enucleated.  When 
the  disease  has  extended  beyond  the  limits  of  the  organ  primarily 
affected  its  removal  becomes  one  of  the  most  difficult  operations  m 
surgery.  Under  such  circumstances  the  tumor  must  be  exposed  by 
an  external  incision ;  this  may  be  accomplished  by  four  methods : 

I.  Langenbeck's  method  consists  of  an  incision  along  the  pos- 
terior border  of  the  ascending  ramus  and  around  the  angle  of  the  jaw 


582  SURGERY    OF   THE    FACE,    MOUTH,   AND   JAWS. 

and  then  upward  through  the  cheek.  A  temporary  resection  of  the 
inferior  maxilla  is  next  made  just  in  front  of  the  angle,  and  the 
articular  end  of  the  bone  is  turned  upward  with  the  soft  tissues  at- 
tached. From  this  incision  the  ascending  pharyngeal,  the  lingual,  the 
facial,  and  the  carotid  arteries  can  be  reached  and  ligated. 

2.  Mikulicz's  method  is  to  make  an  external  incision  from  the 
mastoid  process  to  the  hyoid  bone.  The  ascending  ramus  of  the  inferior 
maxilla  is  then  denuded  of  its  periosteum  from  the  insertion  of  the 
masseter  muscle  as  high  up  as  possible  and  the  ramus  enucleated.  This 
gives  free  access  to  the  tonsillar  region. 

3.  Cheever's  method  consists  of  an  incision  along  the  anterior 
border  of  the  sterno-cleido-mastoid  muscle  from  the  external  ear  in  a 
downward  direction.  Through  this  incision  the  tonsillar  region  is 
reached. 

4.  Senn's  method  is  to  follow  the  lines  of  incision  suggested  by 
Kocher  for  amputation  of  the  tongue  (see  Fig.  281).  By  this  method 
he  reports  a  successful  issue  in  two  cases. 

When  division  of  the  maxilla  is  practiced  the  severed  bone  should 
be  united  with  silver  wire  after  the  removal  of  the  tumor.  After  irriga- 
tion of  the  wound  it  should  be  packed  with  narrow  strips  of  iodoform 
gauze  and  the  external  wound  closed,  except  at  its  lowest  point,  which 
should  remain  open  for  a  few  days  for  the  purposes  of  drainage  and 
irrigation.  The  packing  should  be  removed  at  the  end  of  twenty-four 
hours  and  the  wound  allowed  to  heal  by  granulation. 

Carcinoma  of  the  Salivary  Glands. — Primary  carcinoma  of  the 
salivary  glands  is  not  a  disease  of  very  common  occurrence,  but  it  is 
exceedingly  malignant.  As  a  primary  affection  it  is  more  common  in 
the  parotid  than  in  the  other  salivary  glands. 

Secondary  carcinoma  of  the  submaxillary  glands  associated  with 
carcinoma  of  the  lower  lip,  the  oral  mucous  membrane,  the  gums  and 
the  tongue,  are  of  common  occurrence.  The  primary  form  of  the  dis- 
ease is  rarely  seen  in  these  or  the  sublingual  glands. 

Carcinoma  of  the  parotid  gland  may  be  of  either  the  acinous  or  the 
tubular  variety. 

In  the  acinous  form  the  disease  begins  as  a  proliferation  of  col- 
umnar epithelial  cells  in  an  individual  acinus  or  lobule  of  the  gland. 
Its  malignant  character  is  marked  by  the  scantiness  of  the  stroma,  its 
rapid  growth,  and  the  early  infection  of  the  lymph  glands. 

The  tubular  variety  begins  in  the  tract  of  the  salivary  duct,  and 
appears  in  the  form  of  epithelial  pearls  or  "cell-nests"  of  columnar 
epithelia,  which  arrange  themselves  in  a  manner  similar  to  tubular 
glands.  These  tubules  multiply  and  extend  into  the  substance  of  the 
gland. 

Carcinoma  of  the  parotid  gland  does  not  appear  until  middle  life. 


CARCINOMATA. 


583 


Its  general  clinical  history  is  that  of  carcinoma  of  the  face.  In  persons 
of  fifty  years  of  age  or  more,  a  rapid-growing  tumor  of  the  parotid 
gland  which  infiltrates  the  skin,  and  finally  ulcerates,  is  with  few  ex- 
ceptions a  carcinoma.  Neoplasms  of  heterogeneous  structures  are 
more  frequently  seen  in  the  parotid  gland  than  tumors  of  a  pure  type. 
Figs.  282,  283,  284  are  made  from  sections  taken  from  three  different 
locations  in  the  same  tumor,  and  nicely  illustrate  this  point. 

Fig.  282. 


Mixed  Tumor  of  the  Parotid  Gland.    (A.) 
(Heterogeneous  structure.)     X  50. 


Treatment. — Carcinoma  of  the  parotid  gland  calls  for  early  and 
complete  extirpation,  with  all  surrounding  infected  tissues.  The  na- 
ture of  the  operation  is  somewhat  serious,  and  requires,  on  account  of 
the  important  vessels  in  the  neighborhood,  most  careful  dissection. 
The  extirpation  of  the  gland  results  in  permanent  paralysis  of  the  face, 
and  this  result  should  be  made  perfectly  clear  to  the  patient  before  an 
operation  is  undertaken. 


584 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


Senn  suggests  that  when  a  large  area  of  skin  is  infected,  the  dis- 
eased portion  should  be  included  within  two  elliptical  incisions,  the 
lower  angle  of  which  should  be  so  placed  that  it  will  be  directly  over 
the  point  at  which  the  external  carotid  artery  must  be  ligated.  The 
temporal  artery  should  be  ligated  upon  the  distal  side  of  the  tumor, 
and  secured  by  compression  forceps  upon  the  proximal  side.  Careful 
dissection  of  the  entire  mass  is  required,  and  must  be  carried  down  to 

Fig.  283. 


Mixed  Tumor  of  the  Parotid  Gland. 
(Heterogeneous  structure.)    X  50. 


(B.) 


the  styloid  process.  As  soon  as  the  external  carotid  artery  is  exposed 
it  should  be  grasped  with  the  hemostatic  forceps,  the  tumor  then  re- 
moved and  the  artery  tied  afterward.  The  wound  made  by  such  an 
operation  necessarily  leaves  a  large  opening  which  cannot  be  closed 
except  by  a  plastic  operation.  This  may  be  accomplished  by  taking 
a  flap  from  the  forehead  or  the  scalp,  leaving  it  attached  at  its  base  by 
a  pedicle  until  union  has  taken  place  in  its  new  position.     The  wound 


CARCINOMATA. 


585 


left  by  removing-  the  flap  should  be  at  once  covered  by  skin-grafts  after 
Thiersch's  method.     In  those  cases  in  which  the  skin  can  be  preserved 

Fig.  284. 


Carcinomatous 
structure. 


Mixed  Tumor  of  the  Parotid  Gland.    (C.) 
(Heterogeneous  structure.)     X  5°- 

Senn  exposes  the  gland  by  a  curved  incision,  the  convexity  look- 
ing downward,  and  extending  from  the  mastoid  process  to  near  the 
malar  eminence.  The  tumor  is  then  removed  by  the  method  just  de- 
scribed. 


CHAPTER    LVII. 

MESOBLASTIC  TUMORS. 

Fibromata. 

In  the  connective-tissue  group  of  tumors  are  included  all  those 
neoplasms  which  arise  from  tissues  developed  from  the  mesoblastic 
layer  of  the  germinal  disk  of  Pander.  The  tumors  which  compose  this 
group  have  their  genesis  in  a  matrix  of  misplaced  connective-tissue 
cells,  of  embryonic  type,  of  either  pre-natal  or  post-natal  origin. 
Tumors  of  this  class  may  be,  as  with  the  neoplasms  of  the  epithelial 
group,  either  benign  or  malignant  in  their  character;  innocency  and 
malignancy  depending  upon  the  stage  of  differentiation  reached  by  the 
tumor-cells.  Cells  of  high  differentiation  will  produce  innocent 
tumors;  cells  of  low  differentiation  will  result  in  the  development  of 
malignant  tumors.  Under  the  head  of  benign  mesoblastic  tumors  may 
be  placed  fibroma,  lipoma,  myxoma,  chondroma,  osteoma,  angioma, 
neuroma,  and  lymphangioma.  Some  of  these,  however,  have  a  ten- 
dency under  favoring  conditions  to  undergo  sarcomatous  transforma- 
tion. 

Under  the  head  of  malignant  tumors  of  mesoblastic  origin  are 
placed  the  various  forms  of  sarcoma. 

The  tumors  of  the  mesoblastic  type  which  are  of  most  frequent 
occurrence  in  connection  with  the  face,  mouth,  and  jaws,  are  the 
fibromata,  chondromata,  osteomata,  angiomata,  and  sarcomata.  The 
other  forms  are  so  rare  in  these  locations  that  their  presentation  may 
be  omitted. 

Definition. — Fibroma  (Lat.  £bra^  a  fiber,  and  Gr.  ofxaa  tumor). 

"A  Fibroma  is  a  benign  tumor,  composed  of  mature  fibrous  tis- 
sue produced  from  a  matrix  of  fibroblasts." 

Fibromata  are  the  most  representative  of  the  mesoblastic  tumors, 
and  are  the  most  common.  They  are  to  be  found  in  all  parts  of  the 
body  where  connective  tissue  and  blood-vessels  form  a  part  of  the 
structure. 

The  chief  locations  of  fibrous  tumors  are  the  periosteum,  espe- 
cially of  the  jaws,  the  skin,  the  uterus,  the  ovaries,  the  neurilemma  of 
the  nerves,  the  terminal  or  peripheral  ends  of  nerves, — where  they  form 

586 


MESOBLASTIC    TUMORS. 


587 


painful  tnl)ercles  within  the  subcutaneous  tissue, — the  rectum,  and  the 
naso-pharynx, — where  they  form  polypi. 

Origin. — Fibromata  have  their  origin  in  a  matrix  of  congenital 
fibroblasts,  which  for  some  reason  have  been  arrested  in  the  process  of 
differentiation  during  the  development  of  the  embryo,  and  have  re- 
mained in  a  more  or  less  embryonic  condition  in  the  connective  tissue 
until  some  influence,  either  local  or  general,  has  stimulated  their  dor- 
mant energies  and  powers  of  cell-proliferation  into  activity.  It  is 
thought  by  some  authorities  that  the  matrix  may  sometimes  be  of  post- 
natal origin,  as  it  frequently  occurs  that  such  tumors  develop  in  the 

Fig.  285. 


Fibroma— Keloid— IN  the  Lobe  of  the  Pinna,  associated  with  an  Ear-ring  Puncture. 

(After  Sutton.) 

cicatrices  following  wounds  and  traumatic  injuries  of  any  form  (Fig. 
285),  and  in  the  regenerative  process  following  suppurative  inflamma- 
tion. 

Ziegler  says,  "The  fibromata  are  developed  from  proliferous  con- 
nective-tissue cells." 

Histologically,  a  fibroma  is  composed  of  interlacing  bands  or 
bundles  of  connective  tissue,  often  showing  upon  the  cut  surface  a 
concentric  arrangement  of  the  connective-tissue  fibers  in  various  parts 
of  the  tumor.  These  whorls  are  arranged  around  blood-vessels.  The 
bundles  are  composed  of  long,  slender,  fusiform  or  spindle  cells,  closely 
packed  together  (see  Fig.  286).  These  tumors  usually  possess  a  dis- 
tinct capsule,  which  renders  it  an  easy  matter  to  enucleate  them. 


588 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


Fibromata  may  arise  from  either  the  periosteum  or  the  endosteum. 
Fibrous  epulides  are  usually  periosteal  or  periodontal  in  their  origin, 
while  antral  fibromata  are  endosteal  growths  arising  from  the  muco- 
periosteum  lining  the  maxillary  sinus. 

Varieties. — Fibrous  tumors  are  sometimes  dense  and  firm  as  a 
tendon, — known  as  hard  fibroma;  at  others  soft  and  spongy,  and  desig- 

FlG.  286. 


Fibrous  Tumor  from  the  Antrum  of  Highmore.    X  450.    (After  D.J.  Hamilton.) 
a,  fusiform  nucleus.;  d,  youngernucleus  of  an  oval  shape;  c,  isolated  fibroblast. 


Fig.  287. 


Hard  Fibroma  from  Fascia  of  Rib.     (After  Liicke.) 

nated  as  soft  fibroma.  In  the  former  variety,  the  intercellular  tissue  is 
very  scanty,  and  the  fibrillae  are  arranged  in  compact  wavy  bundles,  or 
in  whorls.  (Fig.  287.)  On  section  they  are  smooth,  glistening,  dense, 
and  of  grayish-white  color.  The  latter  variety,  known  as  soft  fibroma, 
consists  of  a  more  or  less  loose,  spongy,  fibrous  tissue,  abundantly  sup- 
plied with  blood-vessels.  Upon  the  character  of  the  fibrous  tissue 
which  enters  into  the  formation  of  these  growths  will  depend  the  gen- 


MESOBLASTIC   TUMORS.  5^9 

eral  appearance  of  the  tumor,  which  may  be  more  or  less  yellowish, 
glistening,  semi-transparent,  or  gelatinous.  The  ordinary  nasal  poly- 
pus is  a  typical  illustration  of  this  form  of  fibroma.  Degenerative 
changes  frequently  take  place  in  these  tumors,  viz:  myxomatous,  cal- 
careous, colloid,  ulcerative,  and  sarcomatous.  Occasionally  changes 
of  a  higher  degree  take  place.  In  fibrous  tumors  arising  from  the 
periosteum  or  the  endosteum,  ossification  is  most  frequently  seen. 
Whether  this  is  really  the  result  of  changes  produced  by  tendencies 
of  the  tumor  itself,  or  is  the  result  of  misplaced  osteoblasts,  has  not 
been  demonstrated.  These  tumors  are  usually  encapsulated,  and  are 
easily  enucleated,  except  when  inflammatory  adhesions  are  present. 

Causes.— The  essential  cause  of  the  disease  is  the  presence  within 
the  connective  tissue  of  a  matrix  of  embryonic  fibroblasts.  The  excit- 
ing causes  are  chronic  irritation,  traumatic  injuries,  and  inflammatory 
conditions. 

Fibroma  of  the  Gums.— Fibroma  of  the  gums  (epulis)  is  a  tumor 
composed  of  fibrous  tissue,  situated  upon  the  gum,  and  having  its  ori- 
gin from  the  periosteum  of  the  alveolar  process  or  from  the  peridental 
membrane. 

These  growths  will  usually  be  found  associated  either  with  a  tooth 
having  a  carious  cavity  at  the  gingival  margin,  or  with  a  retained  root 
of  a  carious  tooth  which  has  been  covered  by  the  gum,  but  which  has 
caused  a  constant  irritation  of  the  gingival  tissue  by  its  rough  edges; 
or  by  some  preceding  inflammatory  affection  which  has  left  a  chronic 
condition  of  congestion  in  the  alveolar  periosteum  or  the  peridental 
membrane. 

Tumors  of  this  character  are  of  slow  growth,  painless,  and  usually 
composed  of  firm  fibrous  tissue,  covered  with  the  gingival  mucous 
membrane.  (See  Fig.  267.)  In  form  they  may  be  sessile  or  peduncu- 
lated, usually  the  latter.  In  size  they  may  vary  from  a  walnut  to  a 
man's  fist.  Sessile  tumors  of  large  size  exert  great  pressure  upon  the 
alveolar  arches,  changing  the  form  of  the  maxillae,  and  crowding  the 
teeth  out  of  position.  The  lips  are  sometimes  protruded,  the  cheek 
distorted,  and  when  located  in  the  region  of  the  posterior  molars  the 
palate  may  be  encroached  upon.  In  the  pedunculated  form  the  tumor 
may  attain  such  a  size  as  to  preclude  the  possibility  of  closing  the 

mouth. 

The  writer  once  assisted  in  the  removal  of  such  a  tumor,  which 
was  located  between  the  first  and  second  inferior  left  molars,  upon  the 
buccal  aspect  of  the  gum,  in  a  girl  thirteen  years  of  age.  The  tumor 
was  as  large  as  a  Messina  orange,  somewhat  pear-shaped  in  form,  and 
attached  at  the  small  end  by  a  narrow  pedicle. 

Fibromata  associated  with  the  gums  and  the  teeth  are  of  frequent 
occurrence.     The  simple  fibroma  is  the  most  common,  and  it  rarely 


590  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

reaches  a  size  larger  than  a  walnut.  Pure  fibroma  is  occasionally  seen 
in  this  location,  but  in  the  experience  of  the  writer,  fibro-angioma, 
fibro-chondroma,  and  fibro-osteoma  are  much  more  common.  Fibrous 
tumors  in  this  location  are  prone  to  ossification.  Degenerative  changes 
also  frequently  occur  in  them,  ulceration  and  sarcomatous  transforma- 
tion being  the  most  common. 

The  disease  is  one  which  occurs  in  early  life,  and  is  rarely  seen 
after  the  thirty-fifth  year. 

Diagnosis. — In  the  diagnosis  of  fibroma  of  the  gum,  the  fact  that 
hyperplasia  of  the  gingival  festoons  and  fungoid  conditions  of  the 
dental  pulp  (hernia)  may  so  closely  resemble  fibroma  as  to  be  readily 
mistaken  for  that  tumor,  must  not  be  overlooked.  Hyperplasia  of  gum 
festoons  may  be  distinguished  by  its  very  broad  pedicle,  and  by  its  re- 
taining the  general  form  of  the  festoon.  Fungoid  pulps  (hyperplasia 
of  the  pulp,  the  result  of  hernia)  may  be  distinguished  by  the  growth 
being  attached  by  a  constricted  pedicle,  which  arises  from  the  central 
canal  of  the  tooth. 

Fibroma  of  the  gums  is  usually  a  hard  tumor  covered  by  a  healthy 
appearing  mucous  membrane;  its  surface  is  smooth,  sometimes  glis- 
tening. When  large  they  may  become  injured  by  the  closing  of  the 
teeth,  and  the  injury  result  in  ulceration.  Sometimes  they  have  a 
purplish  color,  showing  an  abnormal  supply  of  blood-vessels,  when 
they  are  classed  as  fibro-angioma.  Fig.  288  shows  a  tumor  of  this  char- 
acter removed  from  the  lower  jaw  of  a  young  man  twenty-eight  years 
of  age.  Tumors  of  this  character  are  frequently  erectile.  The  fibro- 
chondromata  and  the  fibro-osteomata  are  very  dense,  and  the  latter  con- 
tain numerous  small  spiculse  of  bone. 

Prognosis. — The  prognosis  of  fibroma  of  the  gum  is  favorable. 
The  character  of  the  tumor  is  benign.  But  in  a  tumor  of  long  stand- 
ing there  is  a  possibility  that  a  sarcomatous  degeneration  may  have 
set  in,  consequently  the  opinion  in  such  cases  should  be  guarded  until 
a  positive  diagnosis  can  be  made  by  the  microscope.  In  simple 
fibroma,  recurrence  does  not  take  place  after  excision. 

Treatment. — Local  remedies  for  the  cure  of  fibroma,  which  stimu- 
late the  absorbents,  are  worse  than  useless,  as  they  only  cause  irrita- 
tion; and  irritation  may  result  in  sarcomatous  degeneration.  Radical 
cure  of  a  fibroma  of  the  gums  can  only  be  effected  by  excision  of  the 
alveolar  process  of  the  jaw.  To  accomplish  this  operation  it  is  first 
necessary  to  extract  a  tooth  upon  each  side  of  the  tumor,  and  then  with 
a  Marshall's  alveolar  saw  (Fig.  289),  or  small  circular  saw  revolved  by 
the  surgical  engine,  divide  the  bone  to  the  base  of  the  alveolar  process 
upon  each  side  of  the  tumor;  then  by  a  horizontal  incision  of  the  bone 
with  the  circular  saw  or  a  metacarpal  saw  uniting  the  perpendicular 
incisions,  the  section  is  removed;  the  same  end  may  be  accomplished 
with  chisel  and  mallet. 


MESOBLASTIC    TUMORS. 


591 


Resection  of  the  jaw  is  only  admissible  when  the  character  of  the 
tumor  is  undoubtedly  malignant. 

Antiseptic  mouth-lotions,  used  with  persistence,  are  the  only  treat- 
ment of  the  wound  required. 

Fig.  288. 


Fibro-Angio.ma  of  the  Lower  Jaw. 

Fig.  289. 


Marshall's  Alveolar  Saw.    Actual  size  shown  in  separate  saw. 

Fig.  290. 


Fibroma— Sessile— OF  the  Lower  Jaw. 

Hemorrhage  may  sometimes  be  troublesome,  but  this  is  usually 
controlled  by  packing  the  wound. 

Fibroma  of  the  Jaws. — Aside  from  fibroma  located  upon  the 
gum,  fibromata  of  the  jaws  are  rare.  The  maxillary  periosteum  and 
bone  are  the  most  frequent  location  of  fibroma.  Fig.  290  is  made  from 
a  plaster  cast  of  a  tumor  of  this  character  located  in  the  lower  jaw. 


592 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


These  tumors  usually  arise  from  one  or  the  other  of  two  situations, 
either  the  maxillary  sinus  or  the  alveolar  processes  of  either  jaw. 
Tumors  of  this  class  located  within  the  antrum  are  capable  of  causing 
great  destruction  of  surrounding  bony  tissue  by  pressure-atrophy. 

Fibromata  in  this  location  are  usually  very  slow  in  their  growth, 
and  their  presence  is  not  recognized  until  the  neoplasm  has  filled  the 
antrum,  and  has  caused  expansion  and  thinning  of  the  walls  of  the 
sinus.  They  may  also  encroach  upon  the  nasal  passages,  and  com- 
pletely fill  them.  Senn  reports  such  a  case,  which  is  illustrated  by 
Figs.  291,  292,  293. 

Fig.  291. 


Enormous  Fibroma  of  the  Superior  Maxilla.    (A.)     (After  Senn. 


Heath  describes  a  case  in  which  the  tumor  "projected  upward 
into  the  orbit,  destroying  the  floor  of  that  cavity,  and  protruding  from 
its  inner  margin  forward  into  the  cheek.  It  had  also  destroyed  the 
anterior  wall  of  the  antrum,  and  displaced  the  malar  bone  forward 
and  outward;  inward  it  projected  into  the  nose  beneath  the  middle 
turbinated  bone,  and  downward  it  made  its  appearance  on  the  surface 
of  the  alveolar  process  in  the  form  of  a  rounded  mass,  destroying  the 
floor  of  the  antrum  in  the  neighborhood  of  the  anterior  molar  teeth. 
Behind,  the  tumor  appeared  in  the  zygomatic  fossa  by  the  absorption 
of  the  outer  surface  of  the  tuberosity  of  the  superior  maxillary  bone." 

Liston  and  Paget  both  record  cases  of  similar  character. 

Fibrous  tumors  arising  from  the  alveolar  process  of  the  upper 
maxilla  sometimes  attain  such  size  as  to  encroach  upon  the  facial  and 


MESOBLASTIC    TUMORS. 


593 


palatal  surfaces,  causing  pressure-atrophy,  and  crushing  in  the  walls  of 
the  antrum,  though  not  actually  involving  the  sinus.  On  the  other 
hand,  although  the  tumor  is  located  upon  the  alveolar  process,  it  may 
secondarily  involve  the  antrum,  destroying  its  walls,  enter  the  nasal 
fossa  and  penetrate  the  palatal  process,  projecting  into  the  mouth. 


Fig.  292. 


Distortion  of  the  Dental  Arch  caused  bv  Enormous  Fibroma.     (B.(    (After  Senn.) 


Tumors  of  this  character  arising  from  the  alveolar  process  of  the 
lower  jaw  may  attain  a  very  considerable  size,  causing  loss  of  bone- 
tissue  by  pressure-atrophy,  and  great  deformity  of  the  face.  A  growth 
of  this  character  located  in  the  anterior  portion  of  the  lower  jaw.  which 
came  under  the  observation  of  the  writer  several  years  ago.  had  so  dis- 
placed the  six  anterior  teeth  and  the  bicuspids  of  the  right  side  that 
they  projected  at  a  right  angle  to  their  normal  position  outward  and 
beyond  the  lower  lip.  The  tumor  seemed  to  grow  from  the  lingual 
surface  and  base  of  the  alveolar  border,  and  in  its  growth  the  entire 
alveolar  process  in  that  location  seemed  to  be  lifted  up  and  rolled  out- 

39 


594 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


ward.  The  privilege  of  taking  a  photograph  or  a  cast  of  the  mouth 
was  dechned  by  the  patient. 

Fibromata  of  the  jaws  associated  with  the  alveolar  process  are 
usually  sessile,  generally  lobulated  and  round  or  oval  in  form,  covered 
by  the  gum-tissue  of  the  part,  and  are  slow  of  growth  and  painless 
unless  irritated.  Tumors  of  this  class  located  in  the  jaws  do  not  as  a 
rule  cause  local  infection  nor  metastatic  deposits. 

Diagnosis. — In  fibroma  of  the  antrum  it  is  by  no  means  always 
possible  to  make  a  correct  diagnosis  until  after  the  removal  of  the 
tumor.     Pain  and  tenderness  are  usually  absent  except  when  the  tu- 

FiG.  293. 


Enormous  Fibroma  of  the  Upper  Maxilla,  showing  Condition  of  Parts  immediately 
AFTER  Excision  OF  Tumor.     (C.)     (After  Senn.) 


mor  is  intimately  associated  with  the  trunk  of  a  nerve  of  sensation, 
upon  which  it  causes  pressure,  or  when  it  is  the  subject  of  septic  infec- 
tion and  inflammation.  The  great  dif^culty  in  the  diagnosis  arises 
from  the  similarity  in  the  symptoms  of  fibroma,  chondroma,  and  slow- 
growing  sarcoma. 

Prognosis. — The  prognosis  is  favorable  even  though  extensive 
loss  of  bone-tissue  may  have  resulted.  Recurrence  does  not  take  place 
after  enucleation  has  been  performed. 

Treatment. — Surgical  treatment  consists  in  the  entire  removal  of 
the  growth.     This  may  be  accomplished  by  enucleation. 

Enucleation  of  a  fibroma  of  the  superior  maxilla  is  best  accom- 


MESOBLASTIC    TUMORS.  595 

plished  by  external  incision,  which  must  be  governed  as  to  location  and 
extent  entirely  by  the  size  of  the  tumor.  In  operations  upon  the  in- 
ferior maxilla  for  the  removal  of  a  large  tumor,  care  should  be  exer- 
cised to  leave  at  least  a  narrow  rim  of  bone  at  the  base  of  the  jaw  rather 
than  to  make  a  complete  exsection  of  the  bone.  The  advantages  of 
this  will  be  readily  understood. 

Small  tumors  may  be  removed  through  the  mouth. 

Fibroma  of  the  Skin. — Fibrous  tumors  frequently  appear  upon 
the  face,  neck,  and  trunk  of  the  body.  Their  growth  is  very  slow  and 
painless,  and  they  rarely  exceed  the  size  of  a  filbert  nut.  They  appear 
first  as  enlargements  in  the  connective  tissue  of  the  skin ;  as  they  grow 
the  skin  is  elevated  by  the  tumor,  which  projects  more  and  more  until 
the  skin  at  its  base  becomes  constricted.  The  weight  of  the  tumor 
causes  elongation,  which  results  in  the  formation  of  a  pedicle.  The 
tumor  contains  in  its  center  the  principal  artery,  which  sometimes,  in 
consequence  of  an  injury  or  of  textural  change  (Senn),  becomes  stran- 
gulated by  a  thrombus,  when  gangrene  results,  and  the  tumor  is 
cured  spontaneously. 

Fibrous  tumors  of  the  face  are  most  often  sessile,  and  are  easily 
enucleated  by  an  incision  over  the  surface  or  at  the  base, 

A  mole  is  a  flat  fibroma  of  the  skin,  of  congenital  origin.  These 
tumors  vary  in  size  from  a  pin-head  to  growths  three  to  four  inches  in 
diameter.  The  increase  in  size  progresses  until  puberty,  when  they 
usually  become  stationary.  It  has  long  been  recognized  that  these 
growths  are  very  prone  to  take  on  carcinomatous  and  sarcomatous 
degenerations.  As  a  consequence  of  this  tendency,  their  early  removal 
should  be  advised.  If  the  area  of  skin  is  large  that  must  be  sacrificed 
in  their  removal,  the  defect  can  be  remedied  by  a  skin  flap  or  Thiersch 
skin-grafts. 


CHAPTER    LVIII. 

CHONDROMATA. 

Definition. — Chondroma  (xoVSpos,  cartilage,  o/xa,  tumor). 

Chondroma  is  a  cartilaginous  tumor, — a  tumor  consisting  of  car- 
tilage. 

Chondromata  are  tumors  composed  histologically  of  hyaline  carti- 
lage. They  occur  in  locations,  principally,  where  cartilage  is  normally 
found,  viz :  associated  with  the  bones  and  within  the  cartilaginous  struc- 
tures of  the  respiratory  organs.  They  are  also  occasionally  found  in 
locations  where  cartilage  has  no  normal  existence.  In  the  former  case 
the  growth  may  be  due,  as  pointed  out  by  Virchow,  to  the  presence  of 
embryonic  or  untransformed  portions  of  cartilage  remaining  in  the 
bones,  and  which  later  take  on  active  cell-proliferation,  thus  becoming 
the  starting-point  of  a  tumor.  The  latter  condition  is  explained  by  the 
modified  theory  of  Cohnheim,  of  a  misplaced  matrix  of  embryonic 
chondroblasts  in  tissues  where  they  have  no  legitimate  presence,  as, 
for  instance,  in  the  parotid  gland,  ovary,  etc. 

Typical  chondromata  are  found  in  the  long  bones,  usually  in  rela- 
tion with  the  epiphyseal  cartilages ;  consequently  they  occur  most  fre- 
quently in  growing  children  and  in  young  adults.  The  long  bones  of 
the  hands  and  feet  are  especially  liable  to  the  affection.  Fig.  294  illus- 
trates a  remarkable  case  of  this  character  published  by  Stendil. 

Chondromata  may  be  described  as  slow-growing,  painless  tumors, 
firm  to  the  touch,  and  always  encapsulated.  During  their  growth  they 
displace  the  soft  tissues,  and  cause  absorption  of  the  bone  from  which 
they  spring,  fashioning  for  themselves  large  cavities  in  which  they  rest. 

.  Calcareous,  mucoid,  and  myxomatous  degenerations  frequently 
occur  in  the  cartilaginous  tumors.  They  are  prone  to  ossification 
and  to  sarcomatous  transformation.  For  the  latter  reason  these 
tumors  have  always  been  looked  upon  with  more  or  less  suspicion. 
Fig.  295  illustrates  the  histologic  structure  of  an  ossifying  chondroma. 

Injuries  of  a  traumatic  nature  seem  to  be  most  prolific  in  causing 
the  disease.  Rachitis  is  a  frequent  exciting  cause.  Sutton  observes 
that  "it  is  a  curious  circumstance  that  the  tissue  of  a  chondroma  re- 
sembles, histologically,  the  bluish,  translucent  epiphyseal  cartilage 
characteristic  of  progressive  rickets." 
596 


CHONDROMATA. 


597 


A  chondroma  consists  of  cartilage  and  connective  tissue;  the  con- 
nective tissue,  however,  is  found  in  Hmited  cjuantity.  The  tumor  is 
composed  of  numerous  lobes  of  var}ing  size,  which  are  separated  from 
one  another  by  the  connective  tissue.  Occasionally  the  fibrous  tissue 
is  largely  in  excess  of  the  cartilage.  Such  tumors  are  termed  fibro- 
chondromata.     In  size,  form,  and  numbers  the  cartilage  cells  vary 

Fig.  294. 


Chondromata — Multiple — in  Lad  Twenty  Years  of  Age.     (After  Stendil.) 


greatly  in  different  tumors,  and  also  in  different  locations  in  the  same 
tumor.  (Warren.)  The  tumor  grows  by  additions  to  its  external  sur- 
face. When  ossification  takes  place,  it  usually  begins  at  the  center  of 
the  tumor.  These  growths  are  sometimes  inclosed  within  a  real  bony 
layer  or  capsule  derived  from  the  bone-tissue  in  which  they  are  formed. 
Diagnosis. — A  chondroma  may  be  recognized  by  its  lobulated  form, 
which   increases   with  the  growth  of  the   tumor,   by   its   density,   ex- 


598 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


cept  in  locations  where  mucoid  or  colloid  degenerations  have  taken 
place,  when  fluctuation  may  be  present ;  by  the  early  age  at  which  they 
appear,  and  the  tendency  which  they  exhibit  to  become  stationary  at 
the  age  of  puberty,  and  by  the  slow  growth  of  the  tumor  and  the  ab- 
sence of  pain  and  tenderness. 

The  disease  in  the  long  bones  is  very  often  multiple,  though  indi- 
vidual chondromata  are  not  uncommon. 

Fig.  295 


Chondioma, 


Cartilage  cells. 


"-■     ><">.:'■..(• 


Bone. 


Chondroma— Ossifying.    X  50. 


Its  slow  growth  and  tendency  to  multiple  formations  differentiate 
it  from  osteo-sarcoma.  Chondroma  may  be  distinguished  from  oste- 
oma by  the  use  of  the  exploring  needle;  chondromata  will  permit  the 
passage  of  the  needle,  while  osteomata  will  not. 

Prognosis. — Pure  chondromata  are  benign  tumors,  and  but  for 
the  tendency  of  these  growths  to  take  on  sarcomatous  transformation 
the  prognosis  would  be  favorable.  Recurrence  sometimes  takes  place 
after  the  removal  of  tumors  located  in  the  maxillae,  which  casts  a  sus- 
picion that  they  may  be  sarcomatous. 


CHONDROMATA. 


599 


Chondroma  of  the  Jaws. — Chondroma  of  the  bones  of  the  face  is 
a  somewhat  rare  alTection,  but  when  it  does  occur  it  is  most  often 
associated  with  the  superior  maxillary  bones.  Chondroma  of  the  in- 
ferior maxilla  is  exceedingly  rare.  The  disease  when  associated  with 
the  superior  maxilla?  may  arise  from  the  surface  of  the  bone,  or  from 
within  the  antrum.  In  the  former  case  it  has  its  origin  in  the  perios- 
teum of  the  jaw;  in  the  latter  it  is  derived  from  the  cndostcuni,  which 
lines  the  cavity  of  the  antrum. 

Heath  describes  four  cases  of  chondroma  of  the  upper  jaw,  and 
four  post-mortem  specimens.  In  three  out  of  the  four  cases  operated 
upon,  the  disease  originated  in  the  antrum  of  Highmore;  and  of  the 
four  post-mortem  specimens  two  had  their  origin  in  this  sinus. 

Fig    2q6 


Chondroma  of  the  Upper  Jaw -Recurrent.     (After  Heath.) 


Chondroma  of  the  antrum  has  a  tendency  to  extend  into  the 
accessory  sinuses,  sometimes  completely  filling  the  nasal  cavity,  the 
frontal  sinus,  and  encroaching  upon  the  orbit,  dislodging  the  eye,  with 
loss  of  sight.  Fig.  296  is  a  case  of  this  character  reported  by  Heath. 
In  two  out  of  the  eight  examples  mentioned,  the  tumor  penetrated  the 
cranium. 

Tumors  of  this  class  may  reach  an  immense  size,  as  in  the  case  of 
Shaughnessy  (Heath),  who  removed  a  cartilaginous  tumor,  together 
with  the  superior  maxillary  bone,  from  a  Hindoo  patient,  which 
weighed  four  pounds. 

Chondroma  of  the  inferior  maxilla  is  observed  in  two  forms,  the 
endosteal  and  the  periosteal.     In  the  endosteal  variety  the  tumor  occu- 


'6oO  SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 

pies  the  cancellated  portion  of  the  bone,  being  covered  by  the  external 
plate  or  compact  tissue  of  the  jaw.  The  periosteal  form  is  located 
upon  the  external  surface  of  the  bone,  and  is  covered  by  the  gum- 
tissue,  and  for  these  reasons  it  becomes  exceedingly  difficult  to  diag- 
nose it  from  the  hard  variety  of  fibroma.  In  the  endosteal  variety  it  is 
also  difficult  to  arrive  at  a  diagnosis  on  account  of  the  similarity  in  the 
clinical  history  of  osteo-sarcoma  of  the  same  location.  The  periosteal 
variety  may  attain  very  large  dimensions,  and  even  cause  death  by  so 
filling  the  mouth  and  crowding  the  tongue  into  the  fauces  as  to  inter- 
fere with  respiration  and  deglutition. 

The  endosteal  form  of  the  disease  does  not  reach  such  large 
dimensions,  but  it  frequently  causes  such  enlargement  of  the  jaw  as  to 
greatly  disfigure  the  patient. 

Sir  Astley  Cooper  reported  a  case  of  periosteal  chondroma 
(Heath)  of  the  lower  jaw  which  first  appeared  near  the  chin,  and  which 
in  a  year's  time  had  reached  the  following  dimensions:  From  side  to 
side  it  measured  five  and  a  half  inches,  and  four  inches  from  the  incisor 
teeth  to  the  limit  of  its  forward  projection,  while  its  circumference  was 
sixteen  inches.  A  tumor  of  still  larger  size  is  to  be  found  in  the 
museum  of  the  Royal  College  of  Surgeons,  London  (Heath),  which 
measures  six  inches  in  depth  and  nearly  two  feet  in  circumference.  In 
the  Heidelberg  Museum  (Weber)  is  another  specimen  which  weighs 
about  three  and  one-half  pounds. 

Briggs  has  reported  a  case  of  osteo-chondroma  of  the  lower  jaw  of 
immense  size,  which  had  a  history  of  twenty-two  years'  growth.  A 
portion  of  the  tumor  projected  from  the  mouth  and  measured  fully  six 
inches  in  diameter.  The  jaws  were  separated  to  a  considerable  extent, 
and  the  mouth  stretched  to  such  a  degree  that  its  original  form  was 
completely  lost,  and  the  only  portion  of  the  lower  face  that  could  be 
seen  was  the  upper  surface  of  the  everted  lower  lip.  The  tumor  was 
very  dense,  irregularly  round  in  shape,  and  occupied  almost  the  entire 
cavity  of  the  mouth.  The  tongue  was  doubled  up  and  forced  back- 
ward. The  teeth,  with  the  exception  of  two  or  three  roots,  were  lost. 
After  removal  of  the  growth  it  was  found  to  be  irregularly  pear-shaped, 
with  an  average  diameter  of  seven  and  a  half  inches,  and  a  circum- 
ference of  about  twenty-three  inches  in  its  largest  part. 

The  clinical  history  of  chondroma  of  the  jaws  is  so  similar  to  that 
of  fibroma  in  this  location  that  it  is  exceedingly  difficult  from  the  gen- 
eral appearance  and  the  progress  of  the  disease,  to  differentiate  be- 
tween them.  Two  points  in  the  history  of  chondroma  may  assist  in 
the  diagnosis:  It  grows  more  rapidly  than  fibroma,  and  shows  a  greater 
tendency  to  recurrence. 

Heath  records  a  case  from  the  practice  of  Lawson  in  which  ten 
operations  were  made  during  eighteen  years  for  recurrence  of  a  chon- 


CHONDRO.MATA.  6oi 

droma  in  the  lower  maxilla  of  a  woman  fifty-seven  years  old  at  the 
last  operation.     The  tumor  weighed  eighteen  ounces. 

Virchow  reports  a  similar  case  in  which  the  tumor  was  removed 
seven  times  at  varying  intervals  of  six  months  to  two  years. 

Treatment. — The  treatment  of  chondroma  of  the  jaws  dififers  little 
from  the  treatment  of  fibroma,  except  that  on  account  of  its  tendency 
in  some  cases  to  recur,  and  its  liability  to  sarcomatous  transformation, 
greater  care  should  be  exercised  in  the  operation  for  its  removal.  .Bet- 
ter include  a  portion  of  healthy  tissue  surrounding  it  and  secure  im- 
munity, than  to  invite  recurrence  by  a  timid  operation. 

Occasionally  it  may  be  necessary  to  perform  partial  or  complete 
exsection  of  the  maxillse  in  order  to  thoroughly  extirpate  the  tumor. 
In  the  majority  of  chondromata  of  the  jaws,  enucleation  can  be  prac- 
ticed; but  to  guard  against  recurrence,  it  is  well  to  curette  the  surface, 
particularly  all  existing  cavities  communicating  with  the  seat  of  the 
tumor,  for  fear  that  portions  of  the  growth  may  be  hidden  within  them. 

Chondroma  of  the  Salivary  Glands. — Chondromata  of  the  soft 
tissues  differ  from  those  having  their  origin  in  connection  with  the 
bones  and  epiphyseal  cartilages,  in  that  the  tissue  of  which  they  are 
composed  is  fibro-cartilage,  although  occasionally  hyaline  cartilage  is 
found  in  these  tissues.  The  parotid  and  the  submaxillary  glands  are 
among  the  most  common  locations  in  which  these  tumors  are  found. 
The  parotid  gland,  however,  is  more  frequently  the  seat  of  the  affection 
than  the  submaxillary.  Bryant  observed  twelve  cases  of  chondroma 
in  the  soft  tissues.  Of  these  nine  occurred  in  the  parotid  gland,  two  in 
the  submaxillary,  and  one  in  the  leg.  Senn  claims  that  chondroma  is 
found  more  frequently  in  connection  with  the  salivary  glands  than  any 
other  form  of  benign  tumor.  Sutton  classes  the  chondromata  of  the 
parotid  gland  as  sarcomata,  for  the  reason  that  the  spindle-celled  sar- 
comata found  in  this  location  are  very  apt  to  contain  cartilage.  These 
neoplasms,  according  to  Ziegler,  are  very  prone  to  exhibit  a  mixed 
type  of  structure,  and  cartilaginous,  mucoid,  sarcomatous,  and  fibrous 
elements  may  all  occur  within  the  same  tumor.     (Figs.  282,  283,  284.) 

Their  origin  has  already  been  suggested  as  dependent  upon  a 
matrix  of  misplaced  embryonic  chondroblasts.  Some  authorities  are 
of  the  opinion  that  these  tumors  arise  from  the  connective  tissue.  Sut- 
ton says,  "It  appears  to  be  an  extremely  easy  task  for  connective  tissue 
to  form  hyaline  cartilage."  Liicke  and  Konig  believe  (Senn)  that  the 
tumor  may  spring  from  the  capsule  of  the  gland,  or  from  the  surround- 
ing connective  tissue. 

These  neoplasms  are  of  slow  growth,  and  they  may  vary  in  size 
from  a  pea  to  a  walnut.  The}^  are  encapsulated,  and  hence  movable. 
In  form  they  are  lobulated,  and  in  their  growth  do  not  involve  the  sur- 
rounding tissues,  but  push  them  aside. 


602  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

A  pure  chondroma  of  the  saHvary  glands  is  rare.  Cartilaginous 
tumors  of  the  parotid  are  prone  to  sarcomatous  transformation. 

Treatment. — The  treatment  of  chondroma  of  the  salivary  glands  is 
enucleation.  Especial  care  should  be  exercised  in  the  operation  for 
the  removal  of  a  parotid  tumor,  to  avoid  injury  to  the  facial  nerve,  or 
cutting  Stenson's  duct,  as  paralysis  might  result  from  the  former,  and 
salivary  fistula  from  the  latter.  Complete  removal  of  the  tumor  is 
necessary  to  avoid  recurrence  of  the  growth,  and  the  possible  danger 
that  recurrence  may  be  accompanied  by  sarcomatous  degeneration. 


CHAPTER  LIX. 
OSTEOMATA. 

Definition. — Osteomata   (Gr.  oo-reoi',  bone;  o/xa^  tumor  i. 

An  osteoma  is  an  osseous  tumor;  a  tumor  consisting  of  osseous 
tissue. 

Senn  defines  an  osteoma  as  "a  tumor  which  possesses  a  structure 
resembling  that  of  cancellated  or  compact  bone,  produced  from  a  con- 
genital or  post-natal  matrix  of  osteoblasts."  Sutton  defines  them  as 
"ossifying  chondromata." 

The  osteomata  include  all  tumors  composed  of  bone-tissue.  These 
formations  have  received  dififerent  names,  according  to  their  location 
and  the  character  of  their  structure.  Hyperostosis  is  a  dififused  and 
extensive  outgrowth  in  a  bone.  An  osteophyte  is  a  small  local  new- 
formation  growing  from  pre-existing  bone-tissue;  when  of  larger  size 
and  assuming  a  more  tumor-like  form,  it  is  termed  an  exostosis.  A 
bony  growth  occurring  within  the  interior  of  bones  is  designated  as 
endostosis.  "Bony  growths  which  are  not  rigidly  connected  with  the 
bone  are  divided  into  mobile  periosteal  exostoses,  which  are  seated  on  the 
periosteum,  though  separate  from  the  bone ;  parosteal  osteomata,  placed 
near  to  the  bone,  but  not  connected  with  it;  independent  osteomata, 
remote  from  the  bone  and  seated  in  tendon  or  muscle ;  and,  finally,  the 
strictly  heteroplastic  osteomata,  which  may  be  seated  in  the  lungs,  cere- 
bral membranes,  diaphragm,  skin  (rarely),  parotid  gland"  (Ziegler), 
testicle,  ovary,  and  eyeball. 

Sutton  divides  the  osteomata  into  three  classes: 

1.  Compact  osteomata. 

2.  Cancellated  osteomata. 

3.  Exostoses. 

Compact  Osteomata. — These  tumors  are  histologically  identical 
with  the  compact  tissue  of  the  shaft  of  long  bones.  This  variety  of 
tumor  may  occur  in  any  part  of  the  skeleton,  but  it  is  most  frequently 
found  in  the  bones  of  the  skull,  frontal  sinus  (Figs.  297,  298),  the  ex- 
ternal auditory  meatus,  and  the  mastoid  process,  and  it  is  occasionally 
seen  upon  the  nasal  process  of  the  superior  maxilla,  the  malar  bone, 
and  the  body  of  the  inferior  maxilla.  Tumors  of  this  class  are  fre- 
quently designated  as  chiirnatcd  osteomata,  or  ivory  exostoses.     They 

603 


6o4 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


consist,  histologically,  of  thick,  ivory-like  osseous  tissue,  having  a  con- 
centric lamellar  arrangement;  the  bone-corpuscles  are  so  arranged  in 
the  lamellae  that  their  prolongations  are  directed  toward  the  periphery 
of  the  tumor.  (Warren.)  They  are  sparingly  supplied  with  blood-ves- 
sels. The  surface  of  the  growth  is  nodular  and  covered  with  perios- 
teum.    In  the  early  clinical  history  of  their  growth  they  are  frequently 


Fig.  297. 


>   \ 


Osteoma  of  the  Left  Frontal  Sinus— Anterior  View.     (After  Sutton.) 


Fig.  298. 


Osteoma  of  Left  Frontal  Sinus,  seen  from  Below.    (After  Sutton.) 


separated  from  the  bone  from  which  they  spring  by  a  thin  layer  of 
fibrous  tissue;  later  they  become  solidly  united  to  the  bone.  These 
tumors  are  usually  located  upon  the  surface  of  bone,  and  are  in  all 
probability  developed  from  the  periosteal  osteoblasts,  or  they  may 
have  their  origin  in  chondromata  (Senn)  which  later  have  become 
ossified. 

Periosteal  or  compact  osteoma  is  the  most  common  variety  asso- 


OSTEOMATA. 


605 


ciated  with  the  facial  bones.  The  simplest  and  most  common  form  is 
the  small,  irregular  osseous  tubercles  so  frequently  seen  upon  the 
lingual  alveolar  plate  of  the  inferior  maxilla  and  upon  the  external 
alveolar  plate  of  both  maxilhe.  More  rarely  the  alveolar  processes  of 
both  jaws  will  present  extensive,  somewhat  evenly  distributed,  diflfuse 
enlargement, — hyperostosis, — having  the  character  of  osteoma  durum,  or 
ivory  exostosis.     Figs.  299,  300  illustrate  this  form  of  growth. 

Fig.  200. 


Hypertrophy  of  the  Jaws  and  Alveolar  Processes — Upper  Jaw.— Natural  Size. 

These  illustrations  are  made  from  casts  in  the  possession  of  the 
writer,  and  are  exact  copies  of  impressions  taken  by  him  of  the  jaws  of 
a  German  girl,  twenty-four  years  old,  kindly  referred  to  him  by  Dr. 
Fiitterer,  of  Chicago. 

Dififuse  hyperostosis  of  the  maxillary  bones  and  upper  bones  of 
the  face  and  cranium  occasionally  occurs.  (Fig.  301.)  This  disease  has 
been  designated  by  Virchow  leontiasis  ossea.  It  is  characterized  by  a 
hyperostosis  that  is  usually  bilateral  and  symmetrical.  It  begins  ordin- 
arily in  the  superior  maxillary  bones,  most  frequently  in  the  antra; 
enlargement  takes  place  in  the  form  of  prominences  upon  the  inner 
walls  of  the  antra,  under  the  skin  of  the  face,  and  projections  into  the 


6o6 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


nasal  passages.     It  exhibits  a  marked  tendency  to  involve  the  bones  of 
the  face  and  the  cranium.     The  disease  is  one  of  youth;  its  course  is  ex- 

Fic.  300. 


Hypertrophy  of  the  Jaws  and  Alveolar  Processes— Lower  Jaw.— Natural  Size. 

Fig.  301. 


Hyperostosis — Leontiasis  Ossea  of  the  Superior  Bones  of  the  Face.    (After  Howship.) 

ceedingly  slow,  but  progressive,  and  tends  to  destroy  life  by  virtue  of 
its  progressive  development.     It  may  begin  in  the  lower  jaw  and  hyoid 


OSTEOMATA. 


607 


bone,  and  extend  upward,  as  in  a  case  recently  reported  by  Brown. 
(Figs.  302,  303.)  The  cause  of  the  disease  is  unknown.  Another  form 
of  hypertrophy  of  the  l)oncs  of  the  face  and  skull  is  shown  in  Figs.  304, 
305.  306,  307.  taken  from  Specimen  No.  10.620  Pathological  Section 
of  the  Army  Medical  Museum,  Washington,  D.  C.  The  subject  was  a 
negro  Avoman.  and  the  photographs  show  a  symmetrical  thickening  of 
all  of  the  bones  of  the  face  and  skull  except  the  lower  jaw.  This 
affection  has  been  termed  by  von  Recklinghausen  pachyakria.  Its 
cause  and  nature  are  unknown. 

Osteoma  of  the  nasal  process  of  the  superior  maxillary  bones  is 
quite  common.  Hutchinson  describes  such  a  case  in  which  the  out- 
growths were  bilateral  and  symmetrical.     (Fig.  308.) 


Fig.   W2. 


Fig.  303. 


Leontiasis  Ossea.     (After  Brown. 


Leontiasis  OssEA.    (Atier  Brown.) 


Hilton,  in  Guy's  Hospital  Reports,  describes  a  case  of  similar 
location  of  the  tumor,  but  of  greater  interest,  from  the  fact  that  after  a 
period  of  years  it  spontaneously  separated  from  its  attachments  and 
was  exfoliated.  "The  patient  was  a  man  aged  thirty-six  years,  who 
had  noticed  twenty-three  years  before  a  pimple  below  the  left  eye,  close 
to  the  nose,  which  he  irritated,  and  from  that  spot  the  tumor  appears 
to  have  originated.  The  tumor  in  its  growth  displaced  the  eyeball, 
giving  rise  to  excruciating  pain,  which  subsided  on  the  burstmg  of 
the  ball.  The  tumor  began  to  loosen  by  a  process  of  ulceration 
around  its  margin  six  years  before  it  fell  out,  which  event  was  unat- 
tended by  either  bleeding  or  pain.  The  tumor  weighed  fourteen  and 
three-quarter  ounces.  It  was  tuberculated  externally,  and  an  irregular 
cavity  existed  at  the  posterior  part.  A  section  of  the  tumor  presented 
a  very  hard,  polished  surface,  resembling  ivory,  and  exhibited  lines  of 


6o8  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

concentric  curves,  enlarging  as  they  were  traced  from  the  posterior 
part.     The  huge  cavity  left  by  the  tumor  was  bounded  below  by  the 

Fig.  304. 


Leontiasis  OssEA.     Negro  Woman  (Army  Medical  Museum). 

floor  of  the  nose  and  antrum,  above  by  the  septum  nasi,  and  externally 
by  the  orbit,  which  had  been  considerably  encroached  upon  by  the 
tumor." 


OSTEOMATA. 


609 


In   this  case  it  seems   quite   evident  that  the  tumor  had   never 
become  solidly  united  to  the  bone  from  which  it  sprang,  but  that  it 


Fin.  305. 


Leontiasis  Ossea.     Negro  Woman  (Army  Medical  Museum). 


was  separated  from  it  by  a  layer  of  connective  tissue,  which  was  prob- 
ably destroyed  by  the  suppurative  process  which  was  going  on  for  so 

40 


6lO  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

many  years  about  the  tumor,  and,  finally  extending  to  all  the  sur- 
rounding soft  tissues,  loosened  it  from  its  attachments. 

Heath  reports  a  similar  case  of  a  young  man,  twenty-one  years  of 
age,  who  was  under  the  care  of  Sir  William  Fergusson.     In  this  case 

Fig.  306. 


Leontiasis  Ossea.     Negro  "Woman  (Army  Medical  Museum). 

the  tumor  occupied  the  left  side  of  the  face,  and  caused  displacement  of 
the  eye.  The  tumor  had  been  growing  for  twelve  years,  but  during  that 
time  the  patient  had  suffered  no  headache  nor  pain  in  the  tumor,  and 
his  sight  had  been  unaffected.     The  tumor,  when  removed,  weighed 


OSTEO.MATA.  6ll 

ten  and  one-half  ounces,  and  consisted,  in  its  anterior  part,  of  nodulated 
bone  as  hard  as  ivory,  and  posteriorly  of  very  dense  ordinary  bone, 
mixed   with   a   small   amount  of  cartilage.     The   tumor   invaded   the 

Fig.  307. 


Leontiasis  Ossea.     Negro  Woman  (Army  Medical  Museum*. 

antrum,  orbit,  and  nasal  fossa.  An  interesting  point  in  this  case  is 
the  fact  that  it  seemingly  illustrates  the  transitional  steps  in  the  con- 
version of  a  cartilaginous  tumor  into  an  osseous  tumor. 

Cancellous  Osteomata. — These  tumors  histologically  resemble  the 
cancellated  structure  of  bone,  and  are  consequently  much  softer  than 
the  "compact  osteomata."    Examples  of  this  variety  of  osteoma  located 


6l2 


SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 


in  the  maxillary  bones  are  very  rare.  These  growths  are  of  spongy- 
texture,  lobulated  in  form,  and  appear  to  be  formed  by  the  ossification 
of  chondromata. 

Vidal  describes  a  very  remarkable  case  of  this  kind,  the  specimen 
of  which  is  preserved  in  the  Musee  Dupuytren,  Paris,  shown  in  Figs. 

Fig.  308. 


Symmetrical  Exostosis  of  the  Nasal  Processes  of  the  Maxill/e.    (After  Hutchinson.) 

Fig    309 


Osseous  Tumor  of  the  Left  Superior  Maxilla.    (Dupuytren.)     (After  Vidal  de  Cassis.) 

309  and  310.  "The  tumor  is  connected  with  the  left  superior  maxilla, 
being  limited  internally  by  the  intermaxillary  suture,  behind  by  the 
pterygoid  process,  above  and  externally  by  the  malar  bone.  The 
tumor  encroaches  considerably  upon  the  cavity  of  the  mouth,  and 
reaches  back  as  far  as  the  front  of  the  spine.  Its  form  is  bilobed,  and 
in  the  deep  sulcvis  between  the  lobes  can  be  seen  a  molar  tooth.  All 
of  the  other  teeth  have  disappeared,  and  there  is  no  trace  of  their 


OSTEOMATA.  613 

alveoli.  The  left  orbit  and  nasal  fossa  arc  not  sensibly  diminished  in 
size,  but  the  cavity  of  the  moutii  is  almost  entirely  occupied  by  the 
posterior  lobe  of  the  lunior.  The  lower  jaw  has  in  this  case  under- 
gone several  remarkable  alterations.  It  must  at  first  have  pressed 
upon  the  growth  and  produced  t-he  deep  sulcus  between  the  lobes,  but 
in  its  turn  the  tumor  has  reacted  upon  the  lower  jaw,  with  the  following 
eflfect:  It  has  caused  a  double  luxation  of  the  jaw,  the  left  condyle 
resting  against  the  base  of  the  zygoma  and  the  glenoid  cavity  being 
filled  with  soft  material.  The  teeth  of  the  left  side  of  the  lower  jaw 
have  disappeared,  and  absorption  of  part  of  the  coronoid  process  and 
the  whole  of  the  alveolus  has  taken  place,  so  that  only  the  base  of  this 
part  of  the  bone  is  left.     The  outer  surface  of  the  tumor  is  smooth,  and 

Fig.  310. 


Osseous  Tumor  of  the  Left  Superior  Maxilla— Lateral  View.      (Dupuytren.) 
(After  Vidal  de  Cassis.) 

presents  numerous  vascular  grooves  of  good  size;  at  many  points  it  is 
perforated  with  holes.  The  vascularity  of  the  other  bones  of  the  face 
does  not  appear  augmented." 

Heath  records  three  other  specimens  of  this  variety  of  osteoma, 
neither  of  which,  however,  was  so  large  as  the  one  just  mentioned. 

The  student  is  referred  to  this  author's  "Injuries  and  Diseases  of 
the  Jaws,"  third  edition,  for  a  detailed  account  of  these  cases. 

Osteoma  of  the  lower  maxilla  is  an  affection  of  rather  rare  occur- 
rence, if  a  judgment  may  be  based  upon  the  limited  number  of  cases 
recorded  in  surgical  literature.  The  disease  appears  in  the  same  forms 
as  in  the  superior  maxilla,  viz,  the  compact  and  the  cancellous  varieties, 
the  compact  or  ivor\^  exostoses  being  the  most  common. 

Tumors  of  this  form  have  a  predilection  for  the  angle  of  the  jaw. 
Out  of  five  cases  of  this  variety  situated  in  the  lower  jaw,  four  were 
located  at  the  angle  and  one  upon  the  lingual  plate  of  the  alveolar 
process  on  either  side  of  the  symphysis,  in  positions  corresponding  to 


6i4 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


the  bicuspid  and  first  molar  teeth.  (Heath.)  They  vary  in  size  from 
two-thirds  Or  three-fourths  of  an  inch  in  diameter  to  three  or  four 
inches.  Their  form  is  lobulated,  and  they  have  smooth  surfaces.  The 
growth  seems  to  form  around  the  angle,  so  that  this  portion  of  the  jaw 
rests  in  a  deep  groove  in  the  surface  of  the  tumor. 

Cancellous  osteomata  appear  in  the  same  locations  of  the  maxil- 
lary bones  as  the  compact  osteomata,  and  they  may  convert  the  entire 

Fig.  311. 


Osteoma  with  Commkncing  Sarcoma.    X  60. 


thickness  of  the  jaw  into  a  lobulated  mass  of  spongy  bone-tissue,  as 
described  in  one  case  by  Heath. 

It  may  also  form  a  distinct  tumor  within  this  cancellated  tissue  of 
the  body  of  the  jaw, — endostosis.  Sir  James  Paget  describes  such  a 
case  in  which  the  tumor  was  located  in  the  interior  of  the  angle  of  the 
jaw,  and  composed  of  hard,  finely  cancellous  bone. 

The  presence  of  osteoma  in  the  parotid  gland  and  other  locations 
where  bone-tissue  does  not  normally  belong  is  explained  in  two  ways: 
either  by  metaplasia  of  the  connective  tissue,  or  by  the  presence  of  a 


OSTKOMATA.  615 

matrix  of  misplaced  embryonic  osteoblasts.  The  latter  explanation 
seems  the  more  rational,  and  more  in  accord  with  physiologic  laws. 

Osteoma  ill  tlu'  parotid  <:;huid  is  mucli  less  frequent  than  chon- 
droma. 

Sarcomatous  transformation  occasionally  takes  jjlace  in  the  osteo- 
mata.  l''!;;-.  31  t  shows  a  commencing-  sarcnniatous  des^'eneration  taking 
place  in  a  tumor  oi  this  character. 

Treatment. —  Unless  the  tumor  interferes  with  speech  or  mastica- 
tion, or  presses  upon  nerves,  or  causes  an  unsightly  deformity,  surgical 
interference  is  not  indicated,  for  these  growths  are  not  painful,  and 
do  not  cause  inconvenience  except  in  the  ways  indicated. 

Accessible  tumors  located  upon  the  surface  of  bones  may  be  re- 
moved with  the  surgical  engine  and  bone  burs,  a  fine  saw,  chisel  and 
mallet,  or  with  strong  cutting  forceps.  Osseous  tumors  which  involve 
the  antrum  and  accessory  sinuses  may  sometimes  require  exsection  of 
the  jaw  for  their  removal. 

If  the  tumor  is  imbedded  between  the  plates  of  the  bone,  it  should 
be  enucleated,  when  located  within  the  jaw,  if  possible,  without  exter- 
nal incision. 


CHAPTER    LX. 

ANGIOMATA. 

Definition. — Angioma  (Gr.  ayydov,  a  vessel;  o,u.a,  a  tumor).  A 
tumor  formed  of  blood-vessels. 

An  angioma  is  a  tumor  composed  of  an  abnormal  development  of 
blood-vessels.  They  may  be  congenital,  may  develop  during  the  first 
few  weeks  after  birth,  or  not  until  late  in  life. 

Angiomata  appear  in  three  forms,  viz:  Simple  nevi,  cavernous  nevi, 
and  plcxifonn  angiomata. 

Origin. — According  to  Senn,  these  tumors  are  derived  from  a 
matrix  of  angioblasts. 

Angioblasts  are  modified  fibroblasts,  and  their  function  is  to  form 
new  blood-vessels.  In  the  growth  of  normal  blood-vessels  the  angio- 
blasts furnish  the  essential  tissue-elements  of  blood-vessels;  after  the 
blood-vessels  reach  their  requisite  normal  size  the  process  becomes 
stationary.  The  cells  from  which  an  angioma  is  developed  observe  no 
such  limitations  of  function,  but  continue  cell-proliferation,  with  the 
result  of  producing  atypical  blood-vessels,  which  are  not  required  by 
the  tissues  in  which  they  are  developed,  and  which  constitutes  the 
tumor-tissue. 

Angiomata  are  generally  described  as  tumors  mainly  composed  of 
blood-vessels,  the  principal  portion  of  which  are  new-formed;  others 
may  be  composed  of  pre-existing  blood-vessels  more  or  less  changed. 
These  changes  consist  chiefly  in  dilatation,  or  thickening  of  the  walls. 

The  majority  of  angiomata  are  congenital,  and  they  possess  a 
tendency  to  spread  or  increase  in  size.  Occasionally,  however,  the 
opposite  condition  takes  place,  and  they  gradually  disappear.  Angio- 
mata frequently  appear  as  complications  in  other  forms  of  tumors,  and 
impart  to  them  most  serious  clinical  features.  They  are  often  com- 
bined with  lipoma,  fibroma,  adenoma,  carcinoma,  and  sarcoma. 
Sarcomatous  transformation  of  an  angioma  is  not  a  rare  feature  in  the 
clinical  history  of  these  growths;  hyaline  and  colloid  change  also 
occasionally  takes  place. 

A  simple  nevus  (capillary  angioma),  or  "birth-mark,"  is  the  most 
common  form  of  angioma.  It  is  an  incipient  form  of  vascular  tumor, 
and  in  its  typical  form  it  is  most  frequently  found  upon  the  skin  of  the 

6i6 


aaOidmata.  617 

face  and  the  orbit.  More  rarely  it  appears  upon  the  hp,  tongue,  buccal 
mucous  membrane,  and  conjunctiva,  varying  in  color  from  a  bright 
pink  to  a  deep  blue.  The  color,  according  to  Billroth,  depends  upon 
the  depth  at  which  they  are  located  in  the  tissues.  The  most  super- 
ficial ones,  known  as  "port-wine  stain,"  are  red,  while  those  situated 
deeper  are  blue.  Sutton  thinks  the  nevus  is  "bright  pink"  when  the 
tumor  is  composed  of  arterioles,  and  of  a  "bluish  tint"  when  composed 
mainly  of  venules.  Such  nevi  may  be  no  larger  than  a  pin-head,  or 
they  may  cover  a  large  portion  of  the  face.  They  consist  of  an  ab- 
normal development  of  arterioles  or  venules  within  the  skin  or  the  sub- 
cutaneous tissue. 

Histologically  they  are  composed  of  minute  but  abnormally  devel- 
oped blood-vessels  imbedded  in  adipose  tissue,  the  vessels  separated  by 
a  greater  or  less  quantity  of  connective  tissue;  communicating  with  the 
nevus  there  are  usually  two  or  more  larger  vessels,  which  are  derived 
from  an  adjacent  artery  or  vein.  The  arterioles  or  venules  are  often 
abnormally  enlarged  or  sacculated.     (Fig.  312.) 

Diagnosis. — The  tumor  may  usually  be  emptied  by  compression 
upon  it,  when  the  color  of  the  overlying  skin  will  become  normal,  but 
sometimes  this  cannot  be  accomplished. 

As  soon  as  the  compression  is  removed,  the  blood  immediately 
returns  to  the  tumor  and  its  color  is  restored. 

In  the  simplest  form  of  nevus  there  is  no  elevation  of  the  growth 
above  the  surrounding  surface;  it  merely  looks  like  a  patch  of  skin  of 
a  different  color  which  has  been  substituted  for  the  normal  tissue.  In 
the  more  complicated  forms  of  this  variety,  the  surface  of  the  growth 
is  slightly  elevated  above  the  surrounding  skin. 

Simple  angiomata  are  quite  frequently  seen  upon  the  vermilion 
border  of  the  lower  lip,  upon  its  inner  aspect,  and  upon  the  mucous 
surface  of  the  cheeks  at  the  angle  of  the  mouth.  They  rarely  in  these 
locations  assume  a  size  larger  than  a  split  pea,  though  they  may  attain 
very  large  dimensions.  Warren  mentions  a  case  in  a  child  which  in- 
volved the  entire  lower  lip  and  extended  to  the  neck.  Simple  angio- 
mata are  also  found  with  considerable  frequency  in  the  tongue.  They 
may  be  simple  or  multiple.  The  venous  variety  is  usually  congenital; 
the  arterial  form  generally  develops  later  in  life.  They  rarely  reach  a 
size  larger  than  a  nut,  are  quite  painless,  and  usually  give  no  incon- 
venience except  from  their  size.  Accident  which  ruptures  the  surface 
is  liable  to  be  followed  by  profuse  and  repeated  hemorrhage.  (But- 
lin.) 

Capillary  angiomata  sometimes  develop  into  the  cavernous  va- 
riety, and  become  formidable  tumors;  on  the  other  hand,  they  occa- 
sionally disappear  spontaneously. 

A  cavernous  nevus  (cavernous  angioma)  may  be  distinguished  from 


6i8 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


the  simple  form  of  nevus  by  the  difiference  in  the  form  of  the  blood- 
vessels. The  tubular  form  is  characteristic  of  simple  nevus,  while  in 
the  cavernous  variety  the  blood-vessels  are  developed  into  a  series  of 
variously-shaped  sacs  or  cavities,  and  separated  from  one  another  only 
by  fibrous  septa,  lined  with  endothelium.  This  form  of  angioma  is 
rarely  congenital,  and  usually  appears  rather  late  in  life.  It  is  of  slow 
growth,  but  often  attains  to  a  large  size.     Many  of  them  are  exceed- 

FiG.  312. 


Nevoid  Growth  of  Cheek.     X  40. 


ingly  sensitive,  and  on  account  of  their  liability  to  hemorrhage  are  often 
dangerous.  Angioma  is  occasionally  found  in  the  antrum,  usually  in 
the  form  of  a  fibro-angioma. 

The  writer  has  seen  one  case  of  this  variety  of  tumor.  It  was 
located  in  the  antrum  of  Highmore,  and  caused  pressure-atrophy  of 
the  walls  of  the  cavity  and  bulging  of  the  roof  of  the  mouth.  The  case 
was  diagnosed  as  probably  sarcoma  of  the  antrum.  The  patient  was 
a  young  Greek,  about  twenty  years  of  age,  in  other  respects  in  good 
health.     Upon  opening  the  antrum  a  gush  of  blood  followed,  which 


ANCilO.MATA. 


619 


was  very  alarming,  threatening  to  choke  the  patient  before  the  hemor- 
rhage conld  be  checked.     By  rapid  work  the  antrum  was  cleared  of 

Fig.  313. 


Fibro-Angioma  of  Antrum  (A)— Fibrous  Portion,    x  50. 

Fig.  314. 


Fibro-Angioma  of  Antrum  (B)— CAvtRNOus  Portion. 

the  growth  by  spoon  curettes,  and  then  tightly  packed  with  gauze. 
The  patient  made  a  good  recovery.  Figs.  313,  314  show  the  character 
of  the  growth. 


620  SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 

Cavernous  angiomata  are  rarely  seen  in  the  tongue.  Bryant  re- 
cords a  case  in  which  the  tumor  occupied  the  Hp  and  right  side  of  the 
anterior  half  of  the  tongue.  The  parts  were  congested,  swollen,  and 
covered  with  large  veins,  and  great  tortuous  arteries  could  be  felt  run- 
ning up  from  the  base  of  the  tongue  to  supply  the  tumor.  Compres- 
sion emptied  the  tumor,  which  again  instantly  refilled  on  removing  the 
pressure.  Fig.  315  illustrates  the  formation  of  an  angioma  as  seen  in 
the  tongue.  Fig.  316  shows  the  structure  of  a  tumor  of  this  character 
in  the  lip. 

Fig.  315. 


Angioma  of  the  Tongue,  showing  Newly- Formed  Blood-Spaces  not  yet  in  Connection 

WITH  Pre-existing  Vessels.    X  330.     (AfterSenn.) 

•a.  angioblast ;  b,  newij  -formed  spaces  filled  with  delicate  fibrous  net -work  and  amorphous  material. 

Cystic  and  warty  degeneration  sometimes  takes  place  in  these 
growths.  Glandular  infection  does  not  take  place,  but  occasionally 
the  lymphatic  vessels  become  dilated  in  the  floor  of  the  mouth  and  the 
neck.  (Butlin.)  These  enlargements  are  painless,  and  if  punctured 
discharge  a  thin,  watery,  albuminous  fluid. 

A  plexiforni  angioma  (cirsoid  aneurism,  or  aneurism  by  anastomo- 
sis) consists  of  a  number  of  abnormally  developed,  tortuous  blood-ves- 
sels, moderate  in  size,  and  arranged  in  a  generally  parallel  direction  to 
one  another,  making  a  tumor  sometimes  of  considerable  size.  These 
tumors  consist  in  some  instances  entirely  of  arteries;  in  others,  of 
veins  only,  or  of  arteries  and  veins  in  about  equal  proportions.  Angio- 
mata of  this  variety  are  exceedingly  rare  in  any  portion  of  the  body, 
but  are  found  most  frequently  about  the  face  and  scalp.  Bruns  de- 
scribes a  remarkable  case  involving  the  face,  forehead,  and  temporal 


ANGIOMATA. 


621 


region.  (See  Fig'.  317.)  The  writer  has  recorded  a  case  of  this  form 
of  angioma  (anastomosing  aneurism)  in  a  young  man  about  twenty-six 
years  old,  in  whom  the  angioma  developed  as  the  result  of  injury  in  the 
extraction  of  the  upper  molar  teeth.  It  involved  the  hard  palate  and 
the  antrum  of  Highmore,  and  seemed  to  be  connected  with  the  pos- 
terior palatine  artery  of  the  right  side.  The  growth  gave  distinct 
pulsations,   which  could  be  felt,  and  which  were  perceptible  to  the 

Fig.  .316. 


Cavernous  Angioma  ok  Lip.    X  50. 


patient.  The  tumor  was  about  an  inch  and  one-half  in  length  by 
about  one  inch  in  width.  This  case  was  treated  by  injection  of  per- 
chlorid  of  iron,  with  complete  cure  of  the  disease,  which  was  demon- 
strated by  its  non-recurrence  two  years  after  the  operation.  Fig.  318 
represents  the  tumor  one  month  before  the  operation.  Fig.  319 
shows  the  increase  in  growth  from  that  time  to  the  date  of  operation, 
and  Fig.  320  the  result  of  the  operation. 

Treatment. — The  treatment  of  angioma  will  varv  with  the  char- 


622 


SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 


acter  and  extent  of  the  disease.  The  galvano-cautery,  coagulating 
injections,  the  hgature,  ignipuncture,  the  appHcation  of  caustics,  and 
excision  constitute  the  principal  surgical  resources  in  the  treatment. 

Fig.  317. 


DissECTicvor   A  Pi  rxitoRM    VncioM'^  of  thi    Forhhi  ad      (Miiller   ifter  Sutton.  1 


Cirsoid  Anelrism  op  the  Antrum  of  Highmore. 


ANGIOMATA. 


623 


Simple  angioma,  "port-wine  stain,"  if  not  larger  than  a  silver  half- 
dollar  piece,  may  be  successfully  treated  by  the  electro-thermal  cautery, 
but  when  of  greater  extent  than  this,  treatment  for  its  removal  is  inad- 
missible.    Treatment  by  electrolysis  should  be  conducted  with  great 

Fig.  319. 


Cirsoid  Aneurism  oi.  the  Antrum  of  HiGHMORt.,  showing  Increa.se  of  Growth, 

Fig.  320. 


Cirsoid  Aneurism  of  the  Antrim  of  Highmore,  showing  Result  of  Operation. 

care.     Only  a  small  part  of  the  discolored  surface  should  be  treated 
at  each  sitting,  and  repeated  at  intervals  of  three  or  four  days. 

Nevi  appearing  in  young  children  should  be  carefully  watched, 
and  if  they  give  evidence  of  growth  they  should  receive  prompt  treat- 
ment.    If  of  small  size,  no  treatment  is  so  successful  as  excision. 


624  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

Sutton  prefers  the  knife  to  electrolysis,  nitric  acid,  ethylate  of 
sodium,  or  the  ligature.  Growing  nevi,  if  left  to  themselves,  may  soon 
pass  the  limits  of  justifiable  surgery.  It  is  therefore  of  the  utmost 
importance  that  operation  be  undertaken  early. 

Butlin  favors  the  galvano-cautery  for  the  removal  of  all  such 
growths  located  in  the  tongue,  on  account  of  the  hemorrhage  which  is 
so  likely  to  attend  an  operation  with  the  knife  or  scissors. 

There  is  less  hemorrhage  attending  the  use  of  the  galvano-cautery 
heated  to  a  dull  red  than  when  a  white  heat  is  used.  No  definite  line 
of  procedure  can  be  laid  down  for  the  treatment  of  cavernous  angio- 
mata  or  cirsoid  aneurisms.  The  surgeon  must  be  governed  by  the 
conditions  surrounding  the  case,  and  the  size  and  location  of  the 
growth. 

Fayrer  successfully  treated  a  case  of  cirsoid  aneurism  of  the  tongue 
by  injections  of  a  strong  solution  of  tannic  acid.  The  writer  succeeded 
in  his  case  of  cavernous  angioma,  which  was  located  in  the  antrum, 
by  breaking  it  up  with  curettes  and  packing  with  gauze,  while  in  the 
cirsoid  aneurism  located  in  the  hard  palate  and  involving  the  antrum 
success  attended  the  injection  of  a  ten  per  cent,  solution  of  the  tincture 
perchlorid  of  iron. 

The  dangers  which  attend  the  treatment  of  such  growths  by  the 
injection  of  coagulating  remedies  are  those  of  embolism,  from  the 
floating  away  of  small  clots  in  the  blood-current,  which  may  become 
lodged  in  the  vessels  of  remoter  regions.  Ulceration  and  suppuration 
have  been  frequent  sequelae  of  the  injection  treatment,  and  instances 
are  on  record  in  which  they  produced  instant  death. 

The  writer  is  of  the  opinion  that  if  the  injection  method  is  used 
the  remedy  employed  should  be  of  such  a  character  and  strength  as  to 
produce  instantaneous  coagulation  of  the  whole  mass  of  blood  con- 
tained in  the  growth,  which  would  reduce  the  dangers  from  embolism 
to  the  minimum. 

In  those  cases  requiring  the  removal  of  any  considerable  amount 
of  skin,  preventing  coaptation  of  the  wound,  the  surface  should  be 
covered  by  a  Wolfe  graft  or  by  Thiersch  grafts. 


CHAPTER  LXI. 
SARCOMATA. 

Definition. — Sarcoma  (Gr.  o-ap^,  flesh,  and  ofjua.,  tumor).  A  sar- 
coma is  a  connective-tissue  tumor,  composed  of  connective-tissue  cells 
and  a  fibrous  stroma. 

Sarcomata  hold  the  same  relationship  to  the  mesoblastic  group  of 
tumors  that  carcinoma  occupies  in  relation  to  the  epithelial  group ; 
namely,  that  of  malignancy. 

Sarcoma  is  composed  of  connective-tissue  cells  in  a  more  or  less 
embryonic  state  of  development,  and  these  cells  so  predominate  in 
number  and  size  as  to  render  the  intercellular  substance  a  secondary 
element  in  the  structure  of  the  tumor. 

Origin. — Sarcoma  may  be  defined,  adopting  the  modified  theory 
of  Cohnheim,  as  "an  atypical  proliferation  of  connective-tissue  cells 
from  a  matrix  of  fibroblasts  of  congenital  or  post-natal  origin." 
(Senn.)  Sarcoma  is  found  invariably  to  originate  in  tissues  which 
belong  to  the  mesoblastic  group,  viz:  in  formed  and  unformed  fibrous 
tissue,  in  cartilage,  in  bone,  and  in  mucoid,  lymphoid,  neurogliar,  and 
adipose  tissue,  and,  according  to  Ziegler,  the  transformation  of  these 
tissues  into  tumor-tissue  is  effected  by  the  growth  and  multiplication 
of  the  constituent  cells. 

Virchow  maintained  that  sarcoma-cells  may  arise  by  proliferous 
multiplication  from  connective-tissue  cells  of  perfectly  normal  appear- 
ance. Ziegler  coincides  with  this  view,  but  says  "it  may  vary  to  this 
extent,  that  the  development  begins  in  tissue  which  is  already  mor- 
bidly altered.  This  new-formed  cartilage  may  pass  into  sarcoma  by 
over-intense  proliferous  growth  of  the  cartilage  cells  and  disappearance 
of  the  matrix  substance.  But  it  is  of  great  interest  to  note  that  cells  which 
form  part  of  what  we  might  call  congenital  heteroplastic  foci  may  often 
serve  as  the  starting-point  of  a  sarcoma." 

In  the  growth  of  sarcoma  the  tumor-cells  never  reach  a  mature 
type,  but  are  always  more  or  less  embryonic  in  character.  This  feature, 
coupled  with  the  marked  tendency  to  infiltrate  and  involve  surrounding 
tissue,  to  recur,  and  to  disseminate  and  form  metastatic  tumors,  indi- 
cates the  malignant  character  of  the  neoplasm. 

Varieties  and  Structure. — The  sarcomata  are  generally  classified 

41  625 


626  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

according  to  their  histologic  structure,  and  with  especial  reference  to 
the  size,  shape,  and  disposition  of  the  cells  and  the  character  and 
amount  of  the  intercellular  substance: 

(  Small  round-celled. 

1.  Round-celled  sarcoma.  <  Large  round-celled. 

(  Lympho-sarcoma. 

2.  Spindle-celled  sarcoma. 

3.  Myeloid  sarcoma  (giant-celled). 

4.  Alveolar  sarcoma. 

5.  Melano-sarcoma. 

Round-celled  Sarcoma. — This  form  of  sarcoma  may  be  divided 
into  three  varieties:  Small  round-celled,  large  round-celled,  and 
lympho-sarcoma. 

Small  round-celled  sarcoma  is  of  a  very  elementary  character  in  its 
construction,  consisting  of  small  round  cells,  blood-vessels,  and  a  very 
limited  quantity  of  intercellular  substance,  which  is  granular  or  slightly 
fibrillated.  The  cells  contain  a  large,  round,  vesicular  nucleus  and  a 
very  limited  amount  of  protoplasm.  (Fig.  321.)  This  is  particularly 
noticed  in  young  sarcomata,  in  which  the  existence  of  the  large  nucleus 
almost  obscures  the  protoplasm.  In  stained  sections  the  nuclei  are 
always  conspicuous  objects.  (Sutton.)  The  vascular  supply  is  usually 
.abundant;  the  blood-vessels  are  large,  and  have  thin  walls;  they  pene- 
:trate  between  the  cells,  and  often  give  rise  to  a  distinct  pulsation  in  the 
tumor.  The  degree  of  vascularity  of  the  sarcomata  will  indicate  the 
;rapidity  of  their  growth.  The  spindle-celled  sarcomata  are  not  so 
vascular  as  the  round-celled  variety,  and  consequently  do  not  grow  so 
rapidly. 

There  are  no  lymphatics  in  any  of  the  sarcomata,  therefore  dissem- 
ination takes  place  through  the  venous  circulation.  It  is  character- 
istic of  the  small  round-celled  variety  of  sarcoma  that  it  grows  rapidly, 
is  soft,  always  infiltrates  the  surrounding  tissues,  recurs  speedily  after 
extirpation,  and  sooner  or  later  causes  metastatic  deposits.  It  occurs 
chiefly  in  the  connective  tissues  of  muscles  and  bones,  and  also  in  the 
skin,  testes,  ovary,  and  lymphatic  glands.  (Ziegler.)  These  tumors 
have  usually  a  milky-white  appearance  on  section,  and  occasionally 
contain  soft,  cheesy  patches.  On  scraping  the  cut  surface,  a  milky 
juice  is  obtained. 

Large  round-celled  sarcoma  diflfers  from  the  variety  just  described 
in  that  the  cells  are  considerably  larger,  often  uniformly  so,  and  have 
an  abundant  protoplasm  and  large,  oval,  vesicular  nucleus.  Many  of 
the  cells  are  binuclear,  and  a  few  multinuclear.  (Ziegler.)  These 
cells  are  so  large  that  they  often  look  like  epithelium.  The  inter- 
cellular substance  is  somewhat  more  abundant  than  in  the  small 
round-celled  variety,  and  is  arranged  in  a  sort  of  net-work,  inter- 


SAKCU.MATA. 


627 


spersed  with  fusiform  and  ramiform  cells,  which  together  form  a  kind 
of  alveolar  reticulum,  in  the  spaces  of  which  are  imbedded  the  large 
round  epithelium-like  cells.  The  vascular  supply  is  not  so  abundant 
as  in  the  preceding  variety,  and  the  vessel-walls  are  usually  thin.  This 
form  of  sarcoma  occurs  in  the  same  locations  as  the  small  round-celled 
variety,  but  it  is  generally  less  malignant,  does  not  grow  so  rapidly 
nor  infect  the  surrounding  tissues  so  quickly,  but  it  may  eventually 
form  metastatic  growths. 

Fig.  321. 


Small  Round-Celled  Sarcoma.    X  1.50. 


Lymphosarcoma  is  a  variety  of  small  round-celled  sarcoma,  but 
whose  structure  somewhat  resembles  the  structural  arrangement  of  a 
lymphatic  gland;  hence  the  name  lympho-sarcoma.  It  possesses  a 
delicate  reticular  stroma,  composed  in  part  of  intercellular  substance 
and  in  part  of  ramiform  cells  whose  processes  anastomose.  Within 
the  meshes  of  this  reticulum  a  multitude  of  small  round  cells  are  im- 
bedded. (Fig.  322.)  The  tumor,  in  general  appearance  and  clinical 
history,  is  not  different  from  the  ordinary  form  of  small  round-celled 
sarcoma.     Both  are  exceedingly  malignant,  both  grow  rapidly,  and 


628 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


both  give  rise  to  metastatic  deposits  which  may  affect  the  entire  organ- 
ism. (Ziegler.)  The  location  of  lympho-sarcoma  is  most  commonly 
in  the  lymphatic  glands  and  the  mucous  membrane.  It  is  not,  how- 
ever, confined  to  these  structures,  but  may  occur  in  other  tissues. 

Lympho-sarcoma  may  be  differentiated  from  hyperplastic  lymph- 
oma by  the  greater  rapidity  of  its  growth,  by  the  tendency  to  extend 
beyond  the  limits  of  the  gland,  and  by  the  formation  of  metastatic 

tumors. 

Fig.  322. 


Lympho-Sarcoma.    X  200. 

Spindle-celled  Sarcoma. — This  variety  of  sarcoma  is  the  most 
common  and  usually  the  least  malignant  of  all  the  tumors  of  this  class. 
The  degree  of  malignancy,  however,  will  depend  upon  the  abundance 
or  scantiness  of  the  stroma.  An  abundant  stroma  indicates  a  slow- 
growing  hard  tumor  with  a  low  degree  of  malignancy,  while  a  scanty 
stroma  will  indicate  a  rapid-growing  soft  tumor  with  a  high  degree  of 
malignancy.  This  form  of  tumor  is  usually  divided  into  two  varieties, 
the  small  and  the  large  spindle-celled  sarcoma.  Senn  thinks  this  sub- 
division is  superfluous,  as  the  difference  between  the  varieties  is  simply 
one  of  size  of  the  cells,  as  the  structure  of  these  tumors  is  the  same. 
These  tumors  are  located  most  frequently  in  dense  fibrous  tissues  like 
the  periosteum,  the  sheaths  of  muscles,  and  the  skin.     They  are  com- 


SARCOMATA. 
Fig.   .-^23. 


629 


Cells  from^a  Spindle-celled  Sarcoma,  treated  fresh  in  a  Solution  of  Sodic  Chlorid. 

X   250.     (After  Perls  ) 

Fig.  324. 


Large  Spindle-celled  Sarcoma.     X  400.     (After  D.  J.  Hamilton.) 
a,  ordinary  spindle  cell ;  b,  branched  flat  cell ;  c,  flat  endothelium-like  cell. 


630 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


posed  of  long  spindle-cells  of  varying  size,  closely  packed  together, 
lying  side  by  side,  and  grouped  into  bundles,  running  in  various  direc- 


FiG.  325. 
I' 


,^ 


Oat-Seed-like  Spindle-celi.ed  Sarcoma.    X  300.     (After  D.J.  Hamilton.) 


Fig.  326. 


Large  Spindle-celled  Sarcoma  (Orbit).    >C  500. 

tions.     (Fig.  323.)     The  cells  lie  with  their  broad  sides  toward  each 
other.     The  difference  in  the  size  of  the  cells  is  very  considerable,  the 


SARCOMATA. 


631 


large  spindle-cells  being  from  three  to  four  times  as  large  as  the  small 
cells.  (Senn.)  On  isolating  the  cells  by  tearing  out  fragments  of  the 
tumor,  they  ^vill  be  found  to  vary  very  greatly  in  shape;  some  will  be 
fusiform,  with  long  prolongations;  others  ramiform,  with  several  pro- 
longations.    (Fig.  324.) 

Another  form  of  sarcoma-cell  has  been  described  and  figured  by 
D.  J,  Hamilton,  which  he  designates  oat-seed-like  spindle-celled  sar- 
coma. The  chief  difference  between  the  ordinary  spindle-cell  and  this 
form  is  that  the  terminations  of  the  spindles  are  more  obtuse.     (Fig. 

3^5-) 

The  intercellular  substance  of  spindle-celled  sarcoma  is  usually 
small  in  quantity,  and  the  blood-vessels  are  located  in  the  axes  of  the 
bundles  of  cells.     (Warren.)     The  reticulum  is  composed  of  delicate 

Fig.  327. 


Giant  Cells  from  SAKCo^L•l.     (Afier  Liicke.) 


connective-tissue  fibers  and  the  fibrillated  prolongations  of  the  fusi- 
form and  ramiform  cells.  (Fig.  326.)  Sarcomata  made  up  of  large 
spindle-cells  are  usually  much  softer  than  the  small-celled  variety. 

Myeloid  Sarcoma  (giant-celled  sarcoma). — This  variety  of  sar- 
coma is  composed  of  tissue  resembling  the  medullary  substance  of 
young  bones.     Its  name  is  derived  from  this  resemblance. 

Myeloid  sarcoma  is  characterized  by  the  presence  of  cells  of  vari- 
ous shapes  and  sizes,  but  principally  of  large  multinuclear  cells, — giant 
cells, — which  resemble  osteoclasts, — the  bone-destroying  cells.  (Fig. 
327.) 

This  form  of  sarcoma  arises  from  bone,  principally  in  the  medul- 
lar}^ canal,  but  tumors  of  a  similar  character  are  found  in  the  periosteal 
and  other  tissues.     Kolliker  is  of  the  opinion  that  the  giant  cells  of  this 


632 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


form  of  sarcoma  act  the  part  of  osteoclasts  by  destroying  the  bone. 
Sections  of  such  tumors  show  thei  giant  cells  imbedded  in  a  matrix  of 
spindle  or  round  cells.  Stellate  and  club-shaped  cells  may  also  be  pres- 
ent.    (Fig.  328.) 

Fig.   -328. 


// 
GiAST-ciiLLED  Sarcoma  FROM  L'ppKR  Ja.v.     ,^  230.    (After  Perls. ) 

Myeloid  sarcoma  occurs  principally  in  the  long  bones,  is  usually 
of  a  deep  red  or  maroon  color,  and  when  fresh  looks  like  a  piece  of 
liver.     (Sutton.) 

The  periosteal  form  of  myeloid  sarcoma  is  most  frequently  asso- 
ciated with  the  alveolar  processes  of  the  jaws,  usually  arising  from  the 

Fig.  329. 


Myeloid  Sarcom--^  of  Superior  Maxilla. 


sockets  of  the  teeth.  Fig.  329  is  a  photograph  of  a  tumor  of  this  char- 
acter which  was  removed  by  the  writer  from  the  upper  jaw  of  a  young 
German  woman.  Two  previous  operations  had  been  made  in  Berlin,  the 
first  in  1894,  the  second  in  August,  1897,  the  last  being  on  October  31, 
1897,  by  the  writer.  Three  years  afterward  there  had  been  no  recur- 
rence.   The  portion  of  the  jaw  exsected  involved  the  floor  of  the  nose, 


SARCOMATA. 


633 


but  this  was  eventually  closed  by  healthy  granulation  tissue.  Sutton 
thinks  the  term  iiiycloid  sarcoma  should  not  be  applied  even  to  tumors 
occupying-  the  central  canal  of  the  long-  l)ones,  unless  the  giant  cells  are 
present  in  such  quantity  as  to  make  up  a  large  part  of  the  tumor.  Fig. 
330  is  from  a  section  of  a  myeloid  sarcoma  of  the  superior  maxilla, 
which  had  its  origin  in  the  alveolus  of  the  right  third  molar  and  in- 
volved the  floor  of  the  antrum  to  the  cuspid  tooth.     Fig  331  is  a  gland 

Fig.  330. 


■  ■ 

Bss^i^iu^y^^i^^BB 

^-':-:vsi 

ims^^^ 

^m^ 

i.'^^m^. 

'":"'-'>'      ■■ 

m 

■■/:^cA'^ 

■  •     --iv  ■ 

■^.i^;^^;-=C^|\) 

M'->-^. 

'^  ->'   '--^-k'- 

-,    •.       - 

m^n 

ivm 

S^"!. 

^^^ 

^•:..  ■•:>  -  -  -. 

n 

> 

> '"^^  IrV--/""  ■ 

v:-%; 

■Hp^'V                 "  ■'^5^ 

■  --.'  ■  -  ■■ 

-■'■■-     >« 

^^^DH^tek.!       :-  '^li 

V 

wKf^^B^^^Bf^  ^  -'  .'.i''^-. 

.,    ■  s     '"■  ^^ 

11^^ 

Myeloid  cells. 


Myeloid  Sarcoma  of  Superior  Maxilla — Region  of  Third  Molar  and  Floor  of  Antrum. 

(A.)    X  50- 


of  Serres  found  in  the  normal  gum-tissue  covering  the  tumor.  Fig. 
332  shows  a  section  of  another  giant-celled  sarcoma  removed  from  the 
upper  jaw  of  a  woman,  aged  thirty-five,  in  which  the  submaxillary  and 
cervical  lymphatic  glands  were  infected.  Fig.  333  is  a  section  of  the 
mucous  membrane  and  gum  covering  the  tumor,  also  showing  giant 
cells. 

In  the  central  or  myelogenous  form  of  sarcoma  the  arteries  are 
so  large  and  so  numerous,  and  their  walls  so  thin,  that  they  frequently 


634 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


impart  pulsation  to  the  tumor.     (Senn.)     In  this  condition  lies  the 
danger  of  mistaking  them  for  aneurisms  of  bone. 

Alveolar  Sarcoma. — Alveolar  sarcoma  is  a  peculiar  type  of  tumor 
in  which  the  cells  and  the  stroma,  contrary  to  the  general  rule,  are 
arranged  after  the  type  of  glandular  tumors  or  epithelial  neoplasms. 
(Fig.  334.)  This  appearance  in  the  structure  of  these  tumors  is  due  in 
part  to  the  epithelial-like  form  of  the  cells,  but  chiefly  to  their  aggre- 
gated arrangement  in  groups  and  the  separation  of  the  groups  by 
fibrous  septa.     (Ziegler.) 

Fig.  3.11. 


Gland  of  Serres — from  the  Gum-Tissue  covering  the  Myeloid  Sarcoma  of  Superior 

Maxilla.     (B.)    X  50. 


Such  an  arrangement  of  cells  and  stroma  closely  simulates  that 
found  in  carcinoma,  and  it  is  sometimes  exceedingly  difficult  to  distin- 
guish between  them.  The  cells  exactly  resemble  epithelial  cells;  they 
are,  like  them,  grouped  in  masses,  and  sharply  distinguished  from  the 
fibrous  reticulum  in  which  they  are  imbedded.  (Ziegler.)  The  retic- 
ulum contains  the  blood-vessels,  and  no  vessels  penetrate  the  cell 
groups,  which  is  another  point  in  the  similarity  of  tumors  of  the  epi- 


SARCOMATA. 


635 


thelial  group.  Sutton  says  it  is  possible  in  carefully  prepared  sections 
"to  distinguish  a  delicate  reticulum  between  the  individual  cells,  a 
condition  never  found  in  carcinoma,"  thus  establishing  the  diagnosis. 
Sarcoma  of  this  variety  is  not  very  common,  and  is  found  principally 
in  the  skin,  muscle,  and  bone.  When  located  in  the  skin,  it  usually 
originates  in  connection  with  warts  and  the  hairy  and  pigmented 
moles. 

Fig.  332. 


Giant  cells. 


Giant  cells. 


Giant  cells. 


Section  of  Giant-celled  Sarcoma  of  Left  Upper  Jaw,  Canine  Region.    Metastasis  of  Sub- 
maxillary AND  Cer\'ical  Lymphatics.      <  300.    Imbedded  Section. 


Melano-sarcoma. — This  variety  of  sarcoma  may  be  composed 
structurally  of  round  or  spindle  cells;  sometimes  the  stroma  presents 
an  alveolar  arrangement.  (Fig.  335.)  The  particular  feature  which 
distinguishes  this  tumor  from  other  sarcomatous  growths  is  the  pres- 
ence within  the  cells,  the  intercellular  substance,  and  the  vessel-walls 
of  a  variable  amount  of  black  or  dark-brown  pigment.     (Fig.  336.) 

Melano-sarcoma  is  the  most  malignant  of  all  the  forms  of  sar- 


636 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


coma.  Its  most  common  seat  is  the  skin,  the  eye,  and  pigmented  warts 
and  moles.  These  growths  are  characterized  by  early  local  and 
regional  infection  and  metastatic  deposits.  Primary  melanotic  sar- 
coma sometimes  occurs  in  tissues  in  which  pigment  material  is  not 
present  in  a  normal  condition  of  the  tissues.  The  origin  of  the  pig- 
ment material  has  not  yet  been  satisfactorily  explained.  Virchow  was 
of  the  opinion  that  the  pigment  was  formed  within  the  cells. 

Fig.  3.33. 


Giant  cells. 


Giant  cells 


^^'^^li-^** 


4r^i^^ 


Giant  cells. 


Section  of  Mucous  Membrane  of  Gum  covering  Giant-celled  Sarcoma  of  Left  Upper 

Jaw,  Canine  Region.    Metastasis  of  Sub-maxillary  and  Cervical 

Lymphatics.     X  300.     Frozen  Section. 

It  has  been  customary  to  explain  the  presence  of  the  pigment 
material  as  derived  from  the  hematin  of  the  blood.  Neuski  found  sulfur 
in  the  pigment  material.  Dressier  found  iron,  and  Rindfleisch  was 
quite  positive  that  the  melanin — the  term  applied  to  the  coloring  ma- 
terial fotmd  in  melano-sarcoma — was  derived  from  the  hematin  of  the 
red  blood-corpuscles.  Senn  is  of  the  opinion  that  the  coloring  material 
is  derived  from  the  "presence  of  pigmented  cells  deposited  in  the  tis- 


SARCOMATA. 


637 


sues  by  errors  of  development, — that  is,  the  existence  of  a  matrix  of 
pigmented  cells." 

The  coloring  material,  according  to  Ziegler,  occurs  chiefly  in  the 
form  of  amorphous  granules,  but  usually  there  are  a  number  of  cells  as 
well,  v/hich  are  diffusely  stained. 

The  color  of  the  tumor  on  section  will  vary  with  the  amount  of 
pigment  material  present.  When  not  extreme,  it  will  appear  brownish- 
gray,  or  show  brown  or  black  patches,  while  in  the  more  marked  cases 
it  will  be  uniformly  black. 


Fig.  334. 


Alveolar  S.^rcoma.     X  100.     (After  Senn.) 


The  pigment-granules  are  found  in  the  body  of  the  cell,  but  never 
in  the  nucleus.  According  to  Warren,  "the  pigment  is  arranged  in 
many  cells,  so  as  to  distend  them  and  alter  their  shape,  the  pigment- 
granules  appearing  as  large,  dark  globular  masses,  the  clear  nucleus 
being  crowded  into  one  corner  of  the  cell."  The  younger  portions  of 
the  tumor  have  no  pigment  material  at  all. 

Melano-sarcoma  should  not  be  confounded  with  sarcomata  which 
have  absorbed  coloring  matter  from  a  blood-clot,  the  result  of  hemor- 
rhage within  their  structure.  The  metastatic  tumors  of  this  variety  of 
sarcoma  closely  resemble  the  primary  growth,  so  far  as  the  pigmenta- 
tion is  concerned.     (Senn.)     (Fig.  337.) 

Mixed-cell  Sarcoma. — These  tumors,  as  their  name  indicates,  are 
composed  of  cells  of  different  forms  and  structure;  there  is  a  mingling 
of  the  round,  the  spindle,  and  the  giant  cells  in  varying  proportions. 


638 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


All  tumors,  in  a  certain  sense,  are  mixed  tumors,  for  none  of  them 
consist  of  a  single  tissue ;  all  possess  fibrous  tissue,  vessels,  and  char- 
acteristic cells ;  but  certain  other  elements  are  found  in  the  mixed 
tumors  in  combination  with  the  true  tumor-tissue,  such  as  cartilage, 
bone,  fibrous  and  myxomatous  tissue  (Fig.  339),  which  changes  the 
character  of  the  neoplasm  and  designates  it  as  a  mixed  tumor.  For  in- 
stance, if  the  fibrous  element  is  in  excess  in  a  sarcoma,  it  is  called  a 
fibro-sarcoma ;  if  cartilage  is  present,  it  is  termed  a  chondro-sarcoma;  if 


Fig.  335. 


Sarcoma— Alveolar— Melanotic.    X  60. 

bone  enters  into  its  composition,  it  is  designated  an  osteo-sarcoma,  and 
so  on.  (Figs.  339,  341,  342,  345.)  Ziegler  says,  "It  is  not  rare  for 
three  or  four  kinds  of  neoplastic  tissue  to  be  found  within  the  same 
tumor." 

Retrogressive  Changes. — Sarcoma  is  prone  to  undergo  retrograde 
changes  early  in  its  clinical  history.  This  is  due  to  the  absence  of 
a  well-developed  reticulum,  the  great  activity  in  cell-multiplication, 
and  the  abnormal  vascular  supply,  both  as  to  the  amount  of  blood  and 


SARCOMATA. 


639 


the  character  of  the  vessels,  which  are  large  and  thin-walled,  often 
appearing  as  mere  channels  between  the  cells. 

Fatty  degeneration  is  the  most  common  retrogressive  change 
which  takes  place  in  sarcoma.  This  is  eminently  true  of  those  forms 
which  are  most  cellular  in  structure  and  most  active  in  growth.  Hya- 
line degeneration  is  not  so  common  in  sarcoma  as  in  carcinoma.  Myx- 
omatous degeneration  is  the  most  frequent  form  of  retrogressive 
change  in  sarcomatous  growths.     (Figs.  338,  339.)     Caseation  is  occa- 

FiG.  336. 


Stroma. 


Stroma. 


Fibrous  septum. 


Melanotic  Sarcoma.    X  150. 


sionally  observed,  but  this,  in  all  probability,  is  the  result  of  infection 
with  the  tubercle  bacillus,  as  it  is  an  open  question  whether  local 
anemia  alone  can  produce  it. 

Ulceration  and  sloughing  is  a  common  occurrence  in  sarcoma, 
and  takes  place  as  soon  as  the  tumor  by  invasion  or  pressure  pene- 
trates the  overlying  tissues  and  reaches  a  free  surface.  Portions  of  the 
tumor  often  break  down  before  this  growth  penetrates  the  overlying 
tissues,  as  the  result  of  the  rupture  of  the  softened  walls  of  the  blood- 


640 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


vessels,  giving  rise  to  extravasations  of  blood,  which  may  result  in 
spurious  blood-cysts,  or,  by  leaving  the  coloring  matter  behind,  lead 
to  a  mistaken  diagnosis  of  melano-sarcoma. 

Sarcoma  frequently  takes  on  transformations  of  its  tissue  into 
higher  physiologic  types.     These  transformations  most  frequently  take 

Fig.  2>37- 


Secondary  Nodules  of  Melano-Sarcoma  in  the  Liver.    (After  Sutton.) 


place  in  connection  with  periosteal  sarcoma  and  sarcomatous  epulides. 
(Fig.  341.)  Chondrification  and  ossification  are  the  two  principal 
types  of  transformation  which  take  place  in  these  tumors. 

Infection  and  Dissemination. — Local  infection  takes  place  by 
cell-migration.  Sarcoma  cells  possess  to  a  higher  degree  than  car- 
cinoma cells  the  power  to  migrate  from  the  primary  tumor  into  the 


SARCOMATA. 


641 


surrounding  connective-tissue  spaces.  These  spaces  serve  the  purpose 
of  a  stroma,  in  which  the  recently  migrated  cells  become  located  and 
establish  independent  foci  of  neoplastic  growth.  Later  the  pre- 
existing connective  tissue  is  absorbed,  and  in  its  place  is  formed  the 
characteristic  reticulum  produced  by  the  growth  of  the  fibrillated  sar- 
coma cells. 

Sarcoma  in  its  growth  displaces  tissue  to  a  much  greater  extent 
than  does  carcinoma;  it  extends  in  the  directions  which  offer  the  least 

Fig.  338. 


Sarcoma  cells. 


My.Komatous 
deeeneraliori. 


MVXO-S.A.RCOMA. 


resistance,  but  no  tissue  is  sufficiently  dense  to  offer  a  permanent  bar- 
rier to  its  extension,  for  eventually  it  attacks  and  destroys  adjacent 
tissue,  regardless  of  its  anatomical  structure.  (Senn.)  Cartilage  of  all 
the  tissues  is  the  last  to  be  invaded  and  destroyed  by  sarcoma. 

Regional  infection  takes  place  by  the  disease  following  the  sheaths 
of  blood-vessels  and  veins,  but  it  is  rarely  disseminated  through  the 
lymphatics.  This  is  explained  by  the  fact  that  sarcomata  have  no 
lymphatic  vessels.  Regional  lymphatic  infection,  therefore,  when  it 
does  take  place  through  the  lymphatics,  must  be  by  migration  of  cells 

42 


642 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


to  vessels  of  this  character  lying  in  the  immediate  neighborhood.  As 
a  rule,  regional  infection  does  not  take  place  so  early  in  sarcoma  as  in 
carcinoma. 

General  dissemination  takes  place  through  the  circulation,  and  it 
occurs  at  an  earlier  period  in  the  life-history  of  sarcoma  than  it  does 
in  carcinoma.     This  may  be  explained  by  the  intimate  and  extensive 


Fig.  339. 


Osteoni 


Round-celiei 
sarcoma. 


Myeloid 
sarcoma. 


Myxomatous 
degeneration. 


■,^^     /'•,"*' 


Sarcoma— Myeloid  and  Osteoid,  with  Myxomatous  Degeneration— of  Inferior  Ma.xilla. 

X  60. 


relationship  which  exists  between  the  blood-vessels  and  the  tissue  of 
the  tumor.  In  this  respect  sarcoma  may  be  said  to  possess  greater 
powers  of  malignancy  than  carcinoma.  General  dissemination  takes 
place  much  more  frequently  in  the  small  round-celled  sarcoma  than  in 
the  spindle  or  giant-celled  variety.  (Senn.)  Metastatic  deposits  are 
most  frequently  found  in  the  lungs,  and  next  in  order  of  frequency  are 
the  spleen,  the  kidneys,  and  the  liver. 


SARCOMATA.  643 

Causes. — "TJic  essential  cause  of  sarcoma  is  the  presence  of  a 
tumor-matrix  of  embryonic  fibroblasts,  of  either  congenital  or  post- 
natal origin,  which  produces  an  atypical  proliferation  of  connective- 
tissue  cells,"  as  a  result  of  irritation  and  especial  environment. 

That  certain  individuals  inherit  a  tendency  or  predisposition  to 
sarcoma  is  generally  recognized.  Sarcoma  as  a  congenital  tumor  is 
very  rare.  Age  does  not  play  so  important  a  part  in  the  predisposition 
to  sarcoma  as  it  does  in  carcinoma.  No  age,  from  infancy  to  extreme 
old  age,  is  exempt  from  the  disease.  It  is  most  frequently  seen  in 
childhood  and  early  adult  life.  Youth  predisposes  to  sarcoma  of  the 
bone;  old  age  to  sarcoma  of  the  glandular  organs.  Chronic  irritation 
and  chronic  inflammatory  conditions  predispose  the  tissues  to  sarcoma- 
tous growths. 

The  exciting  causes  of  sarcoma  are  traumatic  injuries  and  various 
forms  of  irritation.  The  effects  of  traumatic  injuries  are  more  decided 
in  the  production  of  sarcoma  than  in  carcinoma.  The  development 
of  a  sarcoma  at  the  seat  of  a  bruise,  a  contusion,  or  a  fractured  bone 
has  been  frequently  observed.  The  influence  of  chronic  irritation  and 
of  trauma  in  the  production  of  sarcoma  has  been  conclusively  shown 
in  connection  with  the  origin  of  sarcoma  in  warts  and  pigmented 
moles.  Either  of  these  skin  defects  may  remain  entirely  harmless 
throughout  a  lifetime,  but  under  the  provocation  of  chronic  irritation 
or  injury  they  may  take  on  sarcomatous  transformation  and  develop 
into  a  melano-sarcoma.  Upon  the  location  occupied  by  a  sarcoma  and 
the  character  of  its  tissue  will  depend  the  clinical  significance. 

Diagnosis  and  Symptoms. — The  diagnosis  of  sarcoma^  is  often  a 
difficult  matter,  and  involves  a  careful  study  of  the  clinical  history  and 
a  minute  examination,  supplemented  by  an  exploratory  puncture  and 
a  microscopic  examination  of  sections  made  from  fragments  of  the 
tumor  removed  for  that  purpose. 

Two  questions  will  claim  answers  in  each  case  presenting  for 
examination:  First,  Is  it  an  inflammatory  swelling?  Second,  Is  it  a 
malignant  growth?  and  if  so,  is  it  a  sarcoma  or  a  carcinoma? 

The  clinical  history  will  in  a  majority  of  cases  decide  the  first 
question;  if  not,  it  may  sometimes  be  settled  by  an  exploratory  punc- 
ture, while  in  a  case  in  which  a  diagnosis  between  sarcoma  and  gumma 
is  not  clear  the  matter  can  be  cleared  of  doubt  b}^  placing  the  patient 
upon  a  vigorous  anti-syphilitic  treatment  for  a  few  weeks. 

The  second  question  may  be  answered  by  the  clinical  history,  so 
far  as  concerns  the  class  of  malignant  growths  to  which  the  tumor 
belongs, — except  when  the  primary  growth  is  located  in  the  tonsil,  the 
testicle,  or  the  lymphatic  glands, — by  the  early  infection  of  the 
lymphatic  glands  in  carcinoma  and  their  comparative  immunity  in 
sarcoma;  by  the  frequent  presence  of  cysts  in  sarcoma;  by  the  greater 


644  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

mobility  of  the  sarcomatous  tumor;  by  the  freedom  from  early  involve- 
ment of  the  skin;  by  the  enlargement  of  the  superficial  veins,  and  by 
the  greater  rapidity  of  growth  in  sarcoma.  There  are,  however,  excep- 
tions to  this  latter  rule.     Malignant  epulides  grow  slowly. 

The  shape  of  the  tumor  is  also  an  aid  in  the  diagnosis.  A  sar- 
comatous tumor  is  usually  smooth,  globular,  oblong,  flat,  or  spindle- 
shaped  (Senn),  the  form  being  governed  by  the  particular  location  of 
the  tumor  and  the  character  of  the  tissues  in  which  it  is  imbedded. 

Pain  is  not  a  marked  or  constant  symptom.  In  neuro-sarcoma, 
or  where  a  nerve  is  involved  by  pressure,  pain  is  sometimes  severe. 
Central  sarcoma  of  bone  does  not  always  cause  severe  pain.  The  gen- 
eral health  of  the  patient  is  rarely  affected  by  the  disease  until  ulcer- 
ation or  general  dissemination  has  taken  place. 

Prognosis. — The  prognosis  in  sarcoma  is  always  grave,  but  its 
gravity  is  modified  by  the  location  and  accessibility  of  the  tumor.  In 
tumors  located  in  tissues  of  great  physiologic  importance  or  in  close 
proximity  to  vital  organs,  the  prognosis  is  most  grave.  The  most 
malignant  forms  of  sarcoma  are  the  soft,  small-celled  varieties.  These 
grow  rapidly  and  produce  early  regional  infection  and  general  dissem- 
ination. The  degree  of  malignancy  may  be  increased  by  the  rapidity 
of  the  growth.  Melano-sarcoma  is  the  most  malignant  of  all  the 
varieties,  and  is  the  least  amenable  to  treatment.  A  fatal  termination 
takes  place  earlier  in  sarcoma  than  in  carcinoma.  Recurrence  takes 
place  more  frequently  and  more  rapidly  in  sarcoma  than  in  carcinoma. 
Errors  in  diagnosis  are  more  frequently  made  in  the  most  malignant 
varieties  of  sarcoma  on  account  of  the  close  resemblance  between  these 
forms  of  sarcoma  and  inflammatory  swellings. 

The  spindle-celled  and  giant-celled  sarcoma  are  the  most  amenable 
to  treatment,  and  therefore  offer  the  most  favorable  prognosis.  The 
forms  of  sarcoma  which  are  most  favorable  for  operation  are  the 
sarcomatous  epulides  and  myeloid  sarcoma  of  bone.  Recurrence  in 
the  subcutaneous  or  muscular  fascia  is  to  be  treated  by  removal  as 
often  as  it  may  appear,  provided  the  growths  are  accessible  and  the 
general  system  has  remained  free  from  dissemination.  Permanent 
cures  have  sometimes  resulted  from  repeated  operations  for  the  re- 
moval of  recurrent  growths. 

Treatment. — The  character  of  the  treatment  will  depend  upon  the 
variety  of  sarcoma  which  has  to  be  dealt  with,  and  the  tissue  or  organ 
in  which  it  is  located.  Operative  treatment,  to  be  of  any  real  value, 
must  be  undertaken  before  regional  and  general  infection  has 
taken  place.  It  has  been  urged  in  the  treatment  of  carcinoma  that 
early  operation  was  imperative  if  a  successful  issue  was  to  be  looked 
for.  In  the  treatment  of  sarcoma  this  advice  should  be  doubly  empha- 
sized, on  account  of  the  fact  that  local,  regional,  and  general  dissem- 


SARCOMATA.  645 

illation  of  the  disease  takes  place  at  a  much  earlier  stage  in  the  history 
of  sarcoma  than  in  carcinoma,  and  that  for  these  reasons  the  disease 
sooner  passes  beyond  the  limits  of  successful  surgical  procedure. 
(Senn.)  Radical  operations  only  hold  out  any  hope  of  a  cure  of  the 
disease,  and  recurrences  should  be  treated  in  the  same  manner. 

The  removal  of  the  central  myeloid  sarcoma  by  scraping  and  the 
enucleation  of  myeloid  sarcoma  of  the  inferior  maxilla  have  in  a  few 
cases  proved  successful,  but  it  would  be  safer  to  remove  at  the  same 
time  as  much  of  the  surrounding  tissue  as  might  be  done  without 
danger  to  the  patient.  In  sarcoma  of  the  long  bones  and  of  the  soft 
tissues  of  the  extremities,  especially  if  the  tumor  is  of  the  round-celled 
type,  high  amputation  is  often  advised.  Sarcoma  of  the  superior  max- 
illa calls  for  removal  of  the  entire  half  of  the  afifected  side.  When  the 
disease  is  located  in  the  lymph  glands  or  the  tonsils,  operative  treat- 
ment is  of  little  avail,  and  except  as  a  palliative  measure  it  should  be 
rarely  undertaken.  Removal  of  sarcoma  by  excision  should  include 
a  zone  of  apparently  healthy  tissue  from  half  an  inch  to  an  inch  in 
width,  according  to  the  size  of  the  growth  and  its  location.  The  over- 
lying skin  or  mucous  membrane  of  a  sarcoma  should  invariably  be 
removed  with  the  neoplasm. 

From  time  to  time  various  drugs  have  been  lauded  as  curative  in 
sarcoma,  but  after  ample  experience  in  practical  demonstration  it  is 
the  consensus  of  opinion  of  the  most  eminent  surgeons  all  over  the 
civilized  world  that  no  drug  which  has  so  far  been  presented  to  the 
profession  has  any  real  curative  effect  upon  the  disease.  It  has  been 
known  for  a  long  time  that  occasionally  an  intercurrent  attack  of 
erysipelas  has  proved  curative  in  sarcoma. 

Busch  made  the  discovery  of  the  apparent  curative  power  of  ery- 
sipelas in  sarcoma,  and  reported  two  cases  in  which  accidental  inocula- 
tion of  sarcomatous  tumors  with  erysipelas  greatly  reduced  the  size  of 
the  growths,  and  in  one  of  these  cases  which  died  from  facial  erysipelas 
ten  days  after  the  attack  the  autopsy  showed  extensive  fatty  degenera- 
tion of  the  sarcoma  cells.  Fehleisen  made  the  attempt  some  years  ago 
to  cure  sarcoma  and  carcinoma  by  inoculation  with  the  coccus  of 
erysipelas,  but  his  hopes  were  not  realized.  Lately  this  treatment  has 
been  revived  by  hypodermic  injections  of  the  toxins  of  erysipelas  in- 
stead of  the  streptococcus,  for  the  cure  of  inoperable  sarcoma.  The 
toxin  of  the  Bacillus  prodigiosus,  combined  with  that  of  the  Strepto- 
coccus erysipelatus,  increases  its  reaction.  So  far  this  treatment  has 
not  proved  as  successful  as  it  was  hoped  it  would.  More  recently 
serum  from  immunized  sheep  inoculated  with  erysipelas  toxins  has 
been  tried  in  the  same  class  of  cases  with  apparent  success. 


CHAPTER  LXll. 
SARCOMATA  (Continued). 

Sarcoma  of  the  Jaws. 

Of  all  the  tumors  which  affect  the  maxillary  bones,  the  sarcomata 
are  by  far  the  most  frequent.  The  varieties  which  are  found  in  this 
location  are  the  round-celled,  the  spindle-celled,  and  the  giant-celled 
sarcoma.  In  addition  to  the  primary  growths  which  may  appear  in  the 
maxillary  bones  and  their  appendages,  they  are  liable  on  account  of 
their  surroundings  to  be  invaded  by  sarcomatous  growths  arising  in 
the  orbit,  the  nose,  and  the  naso-pharynx.  Sarcomata  of  the  jaws  in 
a  large  majority  of  cases  belong  to  the  mixed-cell  varieties. 

Sarcoma  of  the  jaws  arises  from  three  sources,  the  periosteum, 
the  nmco-periosteum  lining  the  antrum  of  Highmore  and  the  nasal 
fossa,  and  the  cancellated  structure  of  the  bone.  Sarcoma  arising 
from  the  first  two  of  these  sources  usually  belongs  to  either  the  round 
or  the  spindle-celled  variety.  The  round-celled  variety  is  the  most 
malignant,  the  giant-celled  the  most  benign;  while  in  the  mixed-celled 
varieties  the  malignancy  is  governed  by  the  number  of  round  cells 
present  in  the  growth.  The  giant-celled  variety  is  most  often  found 
in  the  cancellated  structure  of  the  body  of  the  lower  jaw. 

The  consideration  of  sarcoma  of  the  jaws  may  be  divided,  for  con- 
venience, according  to  the  location  of  the  tumor,  into  four  heads,  viz: 

Periosteal  Sarcoma; 

Muco-periosteal  Sarcoma; 

Endosteal  Sarcoma  (Myeloid); 

Odonto-sarcoma. 

Periosteal  Sarcoma. — This  variety,  as  already  stated,  may  be 
composed  of  either  the  round  or  spindle-celled  form  of  sarcoma.  Peri- 
osteal sarcoma  may  arise  from  any  surface  of  the  maxillary  bone.  The 
disease  is  most  frequently  associated  with  the  alveolar  processes  and 
the  gum;  less  frequently  with  the  facial  surface,  and  very  rarely  with 
the  palatal  process.  Periosteal  sarcoma  rarely  makes  its  appearance 
before  the  fifteenth  year,  though  it  has  occasionally  been  seen  in  very 
young  children.  The  period  of  life  in  which  it  most  commonly  de- 
velops is  between  the  twentieth  and  the  sixtieth  years  of  age. 

646 


SARCOMATA.  647 

These  tumors  arc  more  frequently  associated  with  the  upper  than 
with  the  lower  jaw,  and  they  sometimes  grow  to  very  large  dimensions, 
and  cause  great  deformity.  Fig.  340,  described  by  Heath,  is  peculiar 
in  the  fact  that  the  disease  involved  both  halves  of  the  superior 
maxilla,  appearing  first  upon  the  left  and  later  upon  the  right  side. 
When  growing  from  the  alveolar  processes  and  gum,  it  appears  in  its 
early  stages  as  a  small,  rounded  tubercle,  generally  of  bright  red  color, 
and  located  between  two  teeth,  being  attached  apparently  to  the  gum, 
sometimes  by  only  a  slender  pedicle.  It  is,  however,  periosteal  or 
peridonteal  in  its  origin,  for  it  is  quite  common  to  find  it  growing  from 
the  alveolus  of  the  tooth,  and  in  intimate  relation  with  the  peridental 

Fig.  340. 


Sarcoma— Round-Cklled— OF  THi-  Supi-rior  Maxiliar\  Bonls,  involving  Both  Sides  of  the 

Face.    (After  Heath.) 

membrane.  As  the  tumor  grows,  it  often  pushes  the  tooth  aside  and 
loosens  it.  Later  the  bone  becomes  softened  and  eroded,  and  the 
whole  structure  of  the  jaw  may  become  involved.  The  small-celled 
varieties  of  sarcoma  are  the  most  destructive.  After  the  tumor  has 
reached  a  size  that  causes  it  to  project  beyond  the  crowns  of  the  teeth, 
it  is  subject  to  various  injuries  from  mastication.  Inflammation  is  in- 
duced, and  ulceration  sets  in,  which  aggravates  the  local  condition, 
and  increases  its  malignant  tendency. 

This  form  of  tumor  is  known  as  epulis.  The  term  epulis  is  given  to 
growths  of  all  forms  which  appear  from  the  gum,  but  its  use  is  gen- 
erally restricted  to  the  periosteal  form  of  sarcoma  of  the  jaAV.  An 
epulis  may  contain  round  cells,  but  it  is  more  commonly  composed  of 
spindle-cells.  Giant  cells  are  also  found  in  these  growths  in  connec- 
tion with  the  round  or  spindle-cells.     (Fig.  341.) 


648 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


Virchow  recognized  two  forms  of  epulis,  the  hard  and  the  soft. 
The  hard  variety  contains  a  large  quantity  of  fibrous  tissue,  a  few  small 
cells,  and  giant  cells  are  seen  scattered  between  the  fibers.  The  soft 
variety  is  quite  vascular,  and  hemorrhage  frequently  occurs  within  its 
substance,  which  after  absorption  of  the  blood  leaves  the  pigment-gran- 
ules behind,  and  gives  the  tumor  a  brownish  hue.  These  tumors  have 
been  designated  pigment  epulis.  Periosteal  sarcoma  springing  from 
the  outer  surface  of  the  ramus  might  readily  be  mistaken  for  a  parotid 
tumor. 

Fig.  341. 


Fibrous 
tissue. 


Blood-vessel. 


.iasuSSi-trft*? 


Epulis  with  Sarcomatous  Cells.    Sarcomatous  Transformation. 


A  common  form  of  mixed-sarcoma  is  the  fibro-sarcoma;  tumors  in 
which  the  fibrous  element  predominates  over  that  of  the  sarcoma  cells. 
These  are  most  frequently  seen  in  relation  with  the  maxillary  bones 
and  alveolar  processes.  Fig.  342  shows  the  structure  of  a  tumor  of 
this  character  which  was  located  in  the  malar  bone. 

Myxomatous  degeneration  frequently  occurs  in  this  variety  of 
sarcoma.  Fig.  345  shows  the  process  taking  place  in  sarcoma  of  the 
malar  bone.     Cartilaginous  transformation  sometimes  takes  place  in 


SARCOMATA. 


649 


the  periosteal  sarcoma  (cliondro-sarconia),  or  ossification  represented 
by  delicate  spiculse  of  bone  may  take  place  (osteo-sarcoma).  Figs. 
343  and  344  represent  an  osteo-sarcoma  of  the  left  side  of  the  inferior 
maxilla  of  a  negro  boy.  Fig.  343  was  made  from  plaster  casts  of  the 
case  before  the  operation.  Fig.  344  shows  the  tumor  after  its  removal. 
The  more  dense  the  tumor  the  slower  is  the  growth,  and  consequently 
there  is  a  diminished  degree  of  malignancy,  as  a  result  of  the  decreased 

Fig.  3-1 2. 


Periarteritis. 


Fibro-Sarcoma  of  the  Malar,  showing  Periarteritis.    X  60. 

liability  to  regional  and  general  infection.  The  disease  if  left  to  run 
its  course,  sooner  or  later  causes  extensive  softening  and  erosion  of  the 
bone  from  which  it  sprang,  and  it  may  involve  the  entire  thickness  of 
the  jaw.  Infection  of  the  lymphatics  takes  place,  and  if  the  patient 
holds  out  long  enough,  the  disease  may  be  disseminated  through  the 
body  by  the  circulatory  system,  producing  metastasis  in  the  lungs,  liver, 
and  kidneys. 

Muco-periosteal    Sarcoma. — The    most   common    location    of    sar- 
coma arising  from  the  muco-periosteum  is  the  antrum  of  Highmore. 


650 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


These  are  often  of  the  giant-celled  or  myeloid  variety.  Figs.  346  and 
347  show  the  pathologic  histology  of  one  of  these  growths.  Sarcoma 
growing  in  this  location  soon  fills  the  cavity  and  produces 
thinning  and  expansion  of  its  walls.  As  the  bone  is  expanded  it  en- 
croaches upon  the  nasal  fossa,  obstructing  the  air-passages  and  inter- 

FiG.  343. 


Osteo-Sarcoma  of  Lower  Jaw.     (A.) 

Fig.  344. 


Osteo-Sarcoma  of  Lower  Jaw.    (B. 


fering  with  nasal  breathing.  Absorption  of  the  orbital  plate  may  also 
take  place  to  such  an  extent  as  to  permit  of  bulging  of  the  floor  of  the 
orbit  and  displacement  of  the  eyeball.  In  the  more  severe  cases  the 
alveolar  and  palate  processes  may  be  depressed;  sometimes  the  palate 


SARCOMATA. 


651 


process  upon  the  affected  side  is  decidedly  convex.  The  nasal  duct  is 
often  implicated,  and  sometimes  complete  stenosis  takes  place.  By 
slow  degrees  the  processes  of  the  tumor  finally  penetrate  the  thin  walls, 
and  implicate  the  skin  of  the  cheek,  or  make  their  way  through  the 
floor  of  the  antrum,  and  involve  the  mucous  membrane  of  the  palate, 
or  following  the  alveolus  of  a  recently-extracted  tooth — which  has  be- 
come loosened  by  the  destruction  of  the  alveolar  process — appear  upon 
the  gum;  or  it  may  project  into  the  nasal  fossa,  where  ulceration  may 

Fig.  345. 


Myxomatous 
degeneration. 


Fibro-Sarcoma  of  Malar  Eone,  showing  My.xomatous  Degeneration.    X  60. 


take  place  and  give  rise  to  frequent  and  sometimes  alarming  recurring 
attacks  of  epistaxis.  The  tumor  sometimes  penetrates  the  posterior 
wall  of  the  antrum,  and  enters  the  zygomatic  and  spheno-maxillary 
fossa, — when  it  may  be  mistaken  for  a  tumor  of  the  parotid  gland, — 
from  which  by  slow  degrees  it  creeps  upward  to  the  temporal  fossa ;  or 
it  may  follow  the  spheno-maxillary  fissure  and  involve  the  tissues  of  the 
orbit;  or  it  may  creep  through  the  sphenoidal  fissure  or  penetrate  the 


652 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


foramen  rotundum,  and  gain  access  to  the  middle  fossa  of  the  cranium. 
This  is  the  most  distressing  form  of  sarcoma  connected  with  the  max- 
illary bones.  It  is  usually  very  malignant,  and  the  least  amenable  to 
surgical  treatment.  Occasionally  a  permanent  cure  is  obtained  by 
complete  excision  of  the  afifected  half  of  the  maxilla,  but  this  to  be  suc- 
cessful must  be  made  while  the  tumor  is  still  confined  to  the  limits  of 
the  antrum;  in  other  words,  during  its  benign  stage.  After  the  walls 
of  the  antrum  have  been  penetrated,  operation  is  of  no  permanent 
value.     As  a  palliative  measure  it  is  sometimes  of  benefit. 

Fig.  346. 


Giant  cell. 


Myeloid  Sarcoma  of  Superior  Maxilla  arising  from  the  Antrum.    X  150. 


The  nasal  passages  and  the  antra  sometimes  become  involved  by 
sarcomata  springing  from  adjacent  parts,  a  fact  which  should  not  be 
lost  sight  of  in  the  study  of  the  clinical  history  of  these  growths.  The 
naso-pharynx  and  the  nasal  fossa  are  the  most  common  locations  from 
which  such  involvement  may  arise. 

The  under  surface  of  the  body  of  the  sphenoid  bone  forms  the 
vault  of  the  naso-pharynx,  which  is  covered  with  the  pharyngeal  mu- 


SARCOMATA. 


653 


cous  membrane.  From  the  muco-periostcum  of  this  region  there  oc- 
casionally develop  spindle-celled  sarcomata.  "It  is  not  uncommon  for 
such  tumors  to  extend  into  and  plug  one  or  both  nasal  fossae,  processes 
of  the  tumor  appearing  at  the  nostril;  or  they  may  extend  downward 
into  the  pharynx  and  impede  deglutition."  (Sutton.)  Tumors  of 
this  character  are  usually  attended  with  severe  and  agonizing  frontal 
headache.     Profuse,  recurring  epistaxis  is  also  a  common  symptom. 

Fig.  347. 


Giant  cell 


Myeloid  Sarcoma  of  Superior  Maxilla  arising  from  thk  Antrum,  showing  Giant  Cklls. 

X  300. 

Sarcoma  originating  in  the  nasal  fossa  and  penetrating  the  maxil- 
lary sinuses  is  not  a  very  frequent  occurrence.  The  disease  is  rarely 
seen  except  between  the  ages  of  fifteen  and  twenty  years.  A  most  re- 
markable case  of  this  character  has  been  reported  by  Moore. 

The  tumor  was  a  mixed-cell  sarcoma,  having  its  origin  in  the  nasal 
septum  and  extending  laterally,  filling  both  antra.  As  the  tumor  grew 
the  face  widened  and  projected  forward,  causing  a  most  dreadful  dis- 
figurement. (Fig.  348.)  Pain  was  absent,  the  sense  of  smell  was 
lost,  and  the  sight  of  the  right  eye  impaired.     Operation  for  the  re- 


6S4 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


moval  of  the  growth  was  undertaken  by  Moore,  but  the  patient  died 
while  undergoing  the  operation,  in  consequence  of  some  interference 
with  respiration.  Fig.  349  is  a  sagittal  section  of  the  facial  region  of 
the  skull  of  this  case,  showing  that  the  sarcoma  was  confined  to  the 
nasal  septum. 

Endosteal  Sarcoma. — This  form  of  sarcoma  is  generally  located  in 
the  lower  jaw,  and  is  usually  designated  as  central  sarcoma,  because 
it  arises  in  the  cancellated  structure  of  the  bone.  When  the  disease  is 
located  in  the  upper  jaw,  it  as  a  rule  arises  in  the  nasal  processes.  They 
are  slow-growing  tumors,  but  they  nevertheless  often  attain  a  very 
large  size.  These  tumors  are  usually  classed  as  giant-cell  or  myeloid 
sarcoma.     They  are  composed  of  cells  of  a  great  variety  of  shapes  and 

Fig.  34S. 


Deformity  produced  by  a  Sa.rcoivia  of  the  Nasal  Septum.     (Moore,  after  Sutton.) 

sizes,  but  the  characteristic  cells  of  the  tumor  are  the  giant  cells.  The 
growth  is  a  soft,  pulpy  tumor,  having  little  intercellular  substance, 
abundant  blood-vessels,  and  in  color  a  brownish  hue.  Contrary  to  the 
usual  order,  though  soft  in  structure,  it  is  the  least  malignant  of  the 
sarcomata  found  in  the  jaws.  Endosteal  sarcoma  by  its  growth  pro- 
duces expansion  of  the  compact  plates  of  the  body  of  the  jaw,  and  de- 
velops a  rounded  or  oval  enlargement  of  the  bone.  The  growth  of  the 
tumor,  however,  is  such  as  to  cause  a  thinning  of  the  bone, — in  the 
long  bones  such  a  condition  sometimes  causes  fracture  upon  very  slight 
exertion, — which  may  finally  be  absorbed  and  permit  the  tumor  to  pass 
the  boundaries  of  the  bone.  Under  such  circumstances,  on  account  of 
the  vascularity  of  the  growth  rhythmical  pulsations  may  sometimes  be 
felt  in  the  tumor,  simulating  aneurism.  The  size  rarely  exceeds  that  of 
an  orange  or  the  fist. 


SARCOMATA.  655 

Sutton  is  of  the  opinion  that  myeloid  sarcoma  of  the  jaws  is  not  a 
disease  of  such  frequency  as  the  text-books  would  indicate,  and  he 
thinks  this  error  is  due  to  the  fact  that  sufficient  attention  has  not 
been  devoted  to  a  study  of  sarcomata  arising  in  connection  with  devel- 
oping teeth.  Tumors  of  various  benign  forms,  such  as  the  fibrous 
odontomes  and  cementomes,  frequently  occur  in  connection  with  the 
developing  teeth.  The  fibrous  odontomes  often  contain  a  few  multi- 
nucleated cells.  It  can  therefore  be  readily  understood  how  such  a 
tumor  as  a  fibrous  odontome  might,  if  surrounded  by  favoring  circum- 
stances, take  on  a  sarcomatous  transformation  of  the  giant-celled 
variety. 

Fig.  349. 


Facial  Region  of  the  Skull  shown  in  Fig.  34S,  seen  in  Sagittal  Section.    The  Sarcoma 
IS  restricted  to  the  Nasal  Septum.     (Moore,  after  Sutton.) 

Odonto-sarcoma. — The  odonto-sarcomata  arise  from  the  follicles 
of  developing  teeth.  These  tumors  belong  to  the  mixed-cell  varieties 
of  sarcoma,  and  are  composed  of  round  and  spindle-cells  with  giant 
cells  interspersed  through  the  substance  of  the  tumor-tissue.  "Sar- 
coma of  a  tooth-follicle  only  occurs  in  children,  and  is  particularly  apt 
to  involve  the  germ  of  the  first  permanent  molar."     (Sutton.)     (Fig. 

350- ) 

In  the  early  history  of  these  growths — like  the  fibrous  odontome 

and  cementome — they  are  distinctly  encapsulated. 

The  reason  why  the  first  permanent  molar  should  be  particularly 

prone  to  the  disease  is  not  forthcoming.     The  clinical  history  of  these 

tumors  is  very  similar  to  that  of  myeloid  sarcoma.       Growth  of  the 


656  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

tumor  causes  expansion  of  the  plates  of  the  alveolar  processes;  penetra- 
tion of  the  tumor  through  its  bony  envelope  generally  occurs  upon  the 
gum,  which  ulcerates  and  gives  rise  to  hemorrhage.  Ulceration  of  the 
gum  is  usually  followed  by  infection  of  the  neighboring  lymphatic 
glands,  and  general  dissemination  may  take  place,  but  in  this  regard 
they  are  no  more  liable  than  the  myeloid  sarcoma. 

Sarcoma  of  the  skin  is  an  exceedingly  rare  affection.  It  is  occa- 
sionally seen,  however,  in  connection  with  pigmented  warts  and  moles, 
when  it  assumes  the  form  of  melano-sarcoma. 

Sarcoma  of  the  Salivary  Glands. — Primary  sarcoma  is  not  in- 
frequently observed  in  the  salivary  glands.  The  parotid  is  more  often 
the  seat  of  the  disease  than  the  submaxillary  or  the  sublingual  gland. 

According  to  Billroth,  about  three-fourths  of  the  tumors  found  in 
the  parotid  gland  are  sarcomatous.     The  period  of  life  at  which  these 


Sarcoma  arising  in  the  Follicle  of  a  Developing  Tooth.    The  Dotted  Lines  indicate 
THE  Amount  of  the  Jaw  removed  at  the  Operation.    (After  Sutton  ) 

tumors  are  most  liable  to  develop  is  between  fifteen  and  twenty-five 
years  of  age.  These  tumors  are  usually  of  the  mixed  type,  chondro- 
sarcoma being  the  most  common  form. 

Primary  sarcoma  of  the  parotid  gland  may  be  described  as  a 
smooth,  lobulated,  oval,  elastic,  rapid-growing  tumor,  located  directly 
in  front  of  or  behind  the  angle  of  the  jaw.  (Fig.  351.)  By  its  rapid 
growth  it  soon  involves  the  entire  gland.  As  the  tumors  increase  in 
size  they  sometimes  become  tuberculous  and  implicate  the  tragus  of 
the  ear.  When  allowed  to  progress  uninterruptedly  "they  burrow 
deeply  within  the  tissues  of  the  neck,  dip  beneath  the  sterno-mastoid, 
and  acquire  attachments  to  the  carotid  sheath;  sometimes  they  creep 
upward  and  adhere  to  the  under  surface  of  the  petrosal,  and  pushing 
toward  the  median  line,  so  bulge  the  pharyngeal  wall  inward  as  to 
impede  deglutition."  (Sutton.)  The  rapid-growing  tumors  are  prone 
to  early  perforation  of  the  capsule,  and  a  tendency  to  involve  the  skin 
and  to  ulcerate.  In  the  growth  of  the  tumor  the  facial  nerve  is  often 
implicated  by  the  extension  of  the  tumor  behind  the  ramus  of  the  jaw. 


SARCOMATA. 


657 


and  occasionally  paralysis  follows.  Scnn  mentions  two  cases  in  which 
paralysis  of  the  facial  nerve  was  a  complication. 

In  structure  these  tumors  exhibit  a  great  variety  of  forms;  some 
may  be  pure  sarcoma,  but  a  majority  of  them  will  be  fibro-,  myxo-,  or 
chondro-sarcoma.  The  pure  sarcoma  is  composed  of  round  or  spindle 
cells,  and  is  inclosed  within  a  capsule  from  the  beginning. 

The  fibro-sarcomata  are  spindle-celled  tumors.  Myxo-sarcomata 
are  composed  of  round  and  spindle  cells,  and  myxoma  cells;  these  tu- 
mors may  attain  the  size  of  a  child's  head.     Tlicy  are  round  and  soft, 

Fig.  351. 


Parotid  Sarcoma  implicating  the  Pinna  in  a  Woman  Thirtv-five  Years  of  Age. 

(After  Sutton.) 

and  the  tissue  of  which  they  are  composed  is  yellowish  or  reddish  in 
color.  The  chondro-sarcomata  are  nodulated  upon  the  surface,  and 
consist  almost  entirely  of  hyaline  cartilage  arranged  in  lobules  bound 
together  by  loose  connective  tissue.  (Sutton.)  The  cartilage  cells 
rarely  possess  capsules,  and  often  present  the  stellate  form  of  imma- 
ture cartilage.  The  chondro-sarcomata  are  prone  to  mucoid  degen- 
eration, while  the  fibro-sarcomata  are  more  liable  to  undergo  a  myxom- 
atous change. 

On  account  of  the  great  variety  of  tissues  found  in  a  sarcoma  of 
the  parotid  gland,  it  often  becomes  exceedingly  difHcult  to  make  a 
positive  diagnosis  as  to  the  character  of  the  tumor.  Sutton  says,  "It  is 
not  unusual  in  sections  from  a  parotid  sarcoma  to  meet  with  spindle 
cells,  cartilage,  myxomatous  tissue,  glandular  acini,  and  fibrous  tissue 

43 


658  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

in  an  area  two  centimeters  square."  As  a  rule,  the  most  complex 
tumors  grow  the  most  rapidly.  Some  of  them  infect  the  lymphatic 
glands  in  their  neighborhood,  while  in  others  the  cells  invade  the  blood- 
vessels and  cause  metastatic  deposits  in  the  lungs.  Operation  to  be 
•SHCcessful  must  occur  while  the  tumors  are  in  their  benign  state. 
After  infiltration  of  the  tissues  takes  place  in  the  rapid-growing 
varieties,  complete  removal  often  becomes  impossible. 

A  fatal  issue  of  the  disease  may  be  from  dysphagia  induced  by 
pressure  upon  the  pharynx;  hemorrhage  from  ulcerative  changes  in  the 
large  vessels  of  the  neck  or  from  secondary  deposits  in  the  lungs,  in- 
ducing broncho-pneumonia.     (Sutton.) 

Sarcomata  of  the  submaxillary  glands  are  most  commonly  of  the 
cartilaginous  type,  and  are  usually  encapsulated  and  readily  enucleated. 
When  they  are  the  seat  of  the  rapid-growing  varieties,  the  whole  gland 
should  be  extirpated,  together  with  the  surrounding  connective  tissue, 
at  least  to  an  extent  that  will  insure  the  removal  of  all  diseased  tissue. 


CHAPTER    LXIII. 
TREATMENT  OF  SARCOMA  OF  THE  JAWS. 

It  is  important  in  all  operations  upon  the  lower  jaw,  even  for  the 
removal  of  new  growths,  to  preserve  the  continuity  of  the  bone  if  possi- 
ble, on  account  of  the  disfigurement  which  so  frequently  takes  place  as 
a  result  of  section  of  the  body  of  the  bone.  The  conservation  of  the 
outlines  of  the  face  must,  however,  give  way  before  the  necessity  of  a 
complete  extirpation  of  the  local  disease. 

In  periosteal  sarcoma  of  the  alveolar  process  and  the  gum,  and  in 
endosteal  myeloid  sarcoma  of  limited  growth,  the  continuity  of  the 
body  of  the  bone  may  in  many  cases  be  preserved.  The  operation  for 
the  removal  of  sarcomatous  growths  confined  to  the  gum  and  alveolar 

Fig.  352. 


Cheek  Retractor. 

process  consists  in  first  extracting  the  teeth  upon  either  side  of  the 
growth,  when  with  scalpel,  chisel,  and  mallet  a  sufficient  amount  of  the 
gum  and  bone  may  be  removed  to  include  not  only  the  growth  itself, 
but  enough  healthy-appearing  tissue  to  insure  a  complete  encompass- 
ment  of  all  the  prolongations  of  the  tumor.  Many  times  this  operation 
may  be  successfully  accomplished  without  external  incision.  Under 
such  circumstances  the  cheek-retractor  (Fig.  352)  will  be  of  great  ser- 
vice in  giving  a  good  view  of  the  parts  to  be  operated  upon.  Occasion- 
ally it  will  be  found  necessary  to  operate  through  external  incisions, 
especially  when  the  growth  is  located  in  the  posterior  part  of  the  jaw. 
The  incision  should  be  made  along  the  lower  border  of  the  jaw,  and  of 
sufficient  extent  to  give  free  access  to  the  parts  to  be  operated  upon. 

In  endosteal  sarcoma,  even  of  limited  extent,  an  external  incision 
will  give  the  most  satisfactory  opportunity  for  a  thorough  operation. 
This  operation  consists  of  first  cutting  through  the  compact  layer  of 

659 


66o 


SURGERY    OF    THE    FACE,    MOUTH,    AXD   JAWS. 


the  bone  at  a  sufficient  distance  from  the  tumor  to  include  a  portion 
of  healthy  bone,  and  afterward,  to  insure  its  complete  extirpation,  cu- 
retting the  cancellated  structure  in  all  directions,  being  sure  to  follow 
up  any  point  of  suspicion.  The  odonto-sarcoma  may  b'e  treated  in  the 
same  manner. 

Fig.  353.    ' 


Excision  of  One-half  of  the  Lower  Jaw;  External  Incision.    (After  Esmarch. 

Fig.  354. 


Disarticulation  of  One-half  of  the  Lower  Jaw  ev  Twisting.     (After  Esmarch.) 

In  periosteal  and  endosteal  sarcomata  which  have  involved  the 
entire  depth  of  the  jaw,  exsection  of  the  diseased  half  often  becomes 
necessary.  Senn  recommends  the  removal  of  the  entire  half  from 
symphysis  to  articulation,  as  he  considers  the  proximal  fragment  is 


TREATMENT  OF  SARCOMA  OF  THE  JAWS. 


66i 


rather  detrimental  to  the  patient  than  useful,  and  the  severity  of  the 
operation  is  not  increased  by  such  a  procedure. 

In  any  case  of  carcinomatous  or  sarcomatous  disease  of  the  jaws, 
no  attempt  should  be  made  to  conserve  the  periosteum. 

Fig.  355. 


Garrhtson's  Operation  for  Partial  Exsection  of  the  Lower  Jaw.     (After  Garretson. 

Fig.  356. 


Incisions  for  Resection  of  the  Upper  Jaw.    (After  Esmaich.) 
I,  Gensoul's;  2,  Velpeau's  ;  3,  Syme's;   4,  Malgaigne's  ;   5,  Nelaton's;  6,  Fergusson's  ;   7,  Dieffen- 
bach's  ;  8,  Weber's  ;  9,  Von  Langenbeck's. 

Resection  of  the  ramus  and  half  of  the  body  of  the  lower  jaw  for 
sarcoma  may  be  accomplished,  after  the  manner  of  Esmarch,  by  an 
incision  begun  close  to  the  posterior  border  of  the  ramus,  on  a  level 
with  the  lobe  of  the  ear;  thence  to  the  angle  of  the  jaw,  and  forward 
along  the  lower  border  to  the  symphysis,  where  it  may  intersect  a 
vertical  incision  at  the  median  line  of  the  lip.  This  flap  is  dissected 
from  the  bone  as  far  as  may  be  without  opening  into  the  cavity  of  the 


662  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

mouth,  and  the  facial  artery  Hgated.  A  central  incisor  tooth  is  then 
extracted.  The  tissues  are  now  tunneled  behind  the  symphysis,  and 
the  bone  divided  with  a  chain  saw  passed  through  the  tunnel,  the 
division  of  the  bone  being  made  from  within  outward.  (Fig.  353.) 
If  the  surgical  engine  is  used,  the  bone  is  divided  from  without  in- 
ward. The  jaw  is  then  freed  from  its  attachments  to  the  soft  tissues 
of  the  floor  of  the  mouth,  and  to  a  point  near  the  temporo-maxillary 
articulation.  The  bone  is  disarticulated  by  forcibly  twisting  it  back- 
ward. (Fig.  354.)  The  object  of  wTenching  the  bone  from  its  joint 
rather  than  by  severing  its  attachments  with  cutting  instruments,  is 
to  prevent  injury  to  the  internal  maxillary  artery.  The  wound  should 
be  closed  by  uniting  the  mucous  membrane  of  the  mouth  with  a  separ- 
ate line  of  sutures  to  exclude  the  fluids  of  the  mouth  from  the  wound. 
The  external  wound  may  be  treated  in  the  usual  manner.  Drainage 
should  be  established  for  a  few  days.  For  partial  exsection  of  the 
lower  jaw  in  which  a  portion  of  the  body  of  the  bone  can  be  conserved, 
Garretson's  operation  made  with  the  drill  and  circular  saw,  driven  by 
the  surgical  engine,  is  par  excellence.  Reference  to  Fig.  355  will  indi- 
cate the  technique  of  the  operation. 

In  operations  for  removal  of  the  entire  inferior  maxillary  bone  the 
incisions  are  the  same  as  for  the  removal  of  one  half,  with  the  excep- 
tion that  the  lip  must  not  be  divided  at  the  median  line,  and  the  hori- 
zontal incision  is  carried  from  the  lobe  of  one  ear  down  to  the  posterior 
border  of  the  ramus  and  beneath  the  jaw  to  the  same  point  upon  the 
opposite  side.  The  jaw  is  divided  at  the  symphysis,  and  each  half  re- 
moved separately. 

For  the  removal  of  the  body  of  the  bone  between  the  angles,  the 
same  incisions  may  be  made,  and  the  jaw  divided  with  the  saws  of  the 
surgical  engine,  or  with  the  chain  saw  at  the  angles. 

The  treatment  of  localized  sarcomatous  growths — epulis  and  en- 
dosteal tumors — of  the  upper  jaw  does  not  differ  from  the  treatment  of 
the  same  affections  in  the  lower  jaw.  In  periosteal  sarcoma  and  in 
sarcoma  involving  the  antrum  of  Highmore,  excision  of  the  affected 
half  or  of  the  entire. jaw  is  imperatively  demanded. 

The  various  incisions  which  have  been  recommended  for  exposing 
the  superior  maxillary  bone  preparatory  to  its  excision,  are  shown  in 
the  accompanying  illustrations.     (Fig.  356.) 

Weber's  incision  is  the  one  most  commonly  practiced,  for  the  dou- 
ble reason  that  it  gives  the  best  exposure  of  the  bone,  and  leaves  the 
least  deformity,  as  it  follows  the  natural  lines  of  the  face.  (Fig.  357.) 
In  this  operation  the  upper  lip  is  divided  through  the  median  line  to  the 
base  of  the  cartilaginous  septum  of  the  nose;  thence  around  the  ala  of 
the  nose  and  upward  along  the  side  of  the  nose  to  a  point  a  little  below 
the  inner  canthus  of  the  eye;  then  outward  along  the  lower  border  of 


TREATMENT    OF    SARCOMA    OF    THE   JAWS. 


663 


the  orbit  to  the  outer  angle  of  the  orbit.  (8,  in  Fig.  356.)  The  flap  is 
then  dissected  from  the  bone  and  turned  outward.  The  orbital  con- 
tents are  next  carefully  detached  from  the  orbital  plate  of  the  maxilla. 
The  malar  bone  is  divided  with  the  chain  saw,  passed  through  the  orbi- 
tal fissure,  along  the  posterior  surface  of  the  malar  bone,  and  out  at  the 
malar  fossa  (Fig.  358), by  means  of  a  curved  needle  armed  with  a  heavy 
silk  ligature.  (Fig.  359.)  The  nasal  process  may  be  divided  with  heavy 
cutting  forceps   (Fig.  360).  and  the  maxillary  bones  divided  at  the 


Fig 


Excision  of  the  Upper  Jaw.— Weber's  Incision.     i,After  Weber.) 

Fig.  358. 


Bone-Section  in  Excision  of  the  Upper  Jaw.    (After  Esmarch.) 


median  line  by  the  chain  saw.  The  saw  is  passed  by  first  puncturing 
the  vault  of  the  mouth  through  the  nasal  fossa,  at  the  junction  of  the 
hard  with  the  soft  palate  on  the  median  line,  with  a  drainage  trocar, 
and  the  saw  is  drawn  through  the  mouth  and  out  at  the  nostril  upon 
the  affected  side.  (Fig.  361.)  The  soft  palate  is  then  separated  from 
the  posterior  border  of  the  palate  by  a  transverse  incision.  The  bone 
may  now  be  loosened  from  its  other  attachments  by  inserting  an  eleva- 
tor into  the  division  made  through  the  malar  bone,  and  then  seized 
with  Fergusson's  lion-jawed  forceps  (Fig.  362),  and  the  bone  twisted 


664 


SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 


from  its  bed.  (Fig-.  363.)  The  internal  maxillary  artery  is  next  se- 
cured and  tied,  but  this  is  not  always  necessary,  for  frequently  it  gives 
no  trouble  from  hemorrhage.  Other  bleeding  points  may  be  treated 
by  torsion;  capillary  oozing  may  be  controlled  with  sponges  wrung  out 
of  hot  water,  or  by  packing.     As  soon  as  hemorrhage  has  ceased,  the 


Fig.  359. 


ChaiiN  Saw. 


Fig.  360. 


Straight  Bone-Cutting  Forceps. 
Fig.  361. 


Showing  Line  of  Median  Bone  Section  a.md  Method  of  Applying  Chain  Saw. 

(After  Esniarch.) 

W'ound  cavity  (Fig.  364)  should  be  packed  with  iodoform  gauze  or 
boric  acid  gauze,  and  the  external  wound  sutured,  and  dressings  ap- 
plied. The  after-treatment  consists  of  frequent  irrigation  of  the  mouth 
with  antiseptic  washes,  and  careful  feeding.  The  packing  should  be 
removed  on  the  third  or  fourth  day,  or  sooner,  if  it  seems  to  cause  irri- 
tation or  there  are  signs  of  suppuration,  which  would  be  indicated  by  a 


TREATMENT    OF    SARCOMA    OF    THE   JAWS. 


665 


rise  in  the  body  temperature.  The  tampon  should  be  replaced  by  a 
smaller  one,  and  changed  thereafter  every  day,  the  wound  being  most 
thoroughly  cleansed  each  time  with  antiseptic  solutions. 

The  writer  prefers  the  surgical  engine  armed  with  suitable  saws  for 
all  sections  of  bone  that  can  be  reached  by  them,  to  the  chain  saw  or 

Fig.  :!)62. 


Lion-Jawed  Forceps. 

Fig.  363. 


Removal  of  the  Bone  with  Fergusson's  Lion-Jawed  Forceps.    (After  Esmarch.) 

Fig.  364. 


Wound  Cavity  after  Resection  of  the  Upper  Jaw.     (After  Esmarch.) 


the  chisel  and  mallet,  on  account  of  the  greater  neatness  and  the  saving 
of  time  in  the  operation. 

In  simultaneous  excision  of  both  halves  of  the  superior  maxilla 
the  same  incisions  are  made  upon  both  sides  as  just  described  for  the 
removal  of  one;  or  Dieffenbach's  median  incision  may  be  practiced. 


666  SURGERY    OF    THE    FACE,    MOUTH,    AND   JAWS. 

(7,  in  Fig.  356.)  This  consists  of  dividing  the  upper  Hp  and  nose  upon 
the  median  line,  and  then  carrying  a  transverse  incision  to  a  point  just 
belov^r  the  inner  canthus  of  each  eye  and  outward,  following  the  margin 
of  the  orbit  to  its  outer  angle. 

For  the  removal  of  portions  of  the  superior  maxillary  bones  be- 
low the  infraorbital  foramen,  Nelaton's  (5,  in  Fig.  356)  or  Weber's  (8, 
in  Fig.  356)  incisions  may  be  employed,  and  the  soft  tissues  raised  from 
the  bone.  After  extracting  an  incisor  tooth,  the  maxilla  is  then  divided 
upon  the  median  line  with  a  narrow  saw  passed  through  the  nostril,  the 
horizontal  section  being  made  with  the  saw  or  chisel  through  the 
malar  process  and  the  maxillary  tuberosity.  The  soft  palate  is  de- 
tached by  a  transverse  incision.  The  detached  piece  is  then  loosened 
with  an  elevator  and  wrenched  out  of  its  position. 

Operations  requiring  the  removal  of  only  small  sections  of  the 
alveolar  process  can  with  safety  to  the  success  of  the  operation  be  made 
through  the  mouth. 

The  operations  for  the  extirpation  of  the  parotid  and  submaxillary 
glands  have  already  been  described  in  the  section  on  carcinoma  of  the 
salivary  glands. 


CHAPTER    LXIV. 

ODONTOMATA. 

Definition. — Odontome  (from  the  Greek  oSoWo?,  tooth,  and  ofxa^ 
tumor). 

An  odontome  is  a  tooth-tumor;  a  tumor  composed  of  dental  tis- 
sues in  varying  degrees  of  development  and  in  various  proportions. 

Tumors  arising  from  tooth-germs  are  more  common  in  the  lower 
animals  than  in  man.  The  animals  in  which  they  are  most  frequently 
found  are  the  goat,  sheep,  bear,  lion,  marmot,  agouti,  porcupine,  kan- 
garoo, horse,  and  elephant. 

The  odontomata  are  growths  belonging  to  the  composite  group  of 
tumors.  They  are  composed  of  tissues  which  arise  from  abnormal 
conditions  of  the  enamel-organ,  from  the  capsule,  from  the  papilla,  or 
from  the  entire  germ.  Fig.  365  shows  the  structures  of  a  developing 
tooth-germ.  According  to  Sutton,  the  tumors  which  arise  from  the 
tooth-germ  in  part  or  in  whole  are, — 

1st.  Those  which  develop  from  the  enamel-organ:  Epithelial 
odontomes. 

2d.  Those  which  develop  from  the  capsule:  Fibrous  odontomes, 
cementomes,  compound  follicular  odontomes. 

3d.     Those  which  develop  from  the  papilla:  Radicular  odontomes. 

4th.  Those  which  are  formed  from  the  entire  germ:  Composite 
odontomes. 

From  the  foregoing  classification  it  will  be  noticed  that  Sutton 
classifies  the  odontomata  according  to  the  particular  region  from  which 
these  tumors  have  their  origin. 

Broca,  in  his  "Treatise  on  Tumors,"  classified  the  odontomata 
according  to  the  period  of  their  origin,  and  divided  them  into  four 
classes,  viz:  Odontomes  embryoplastiques,  odontomes  odontoplas- 
tiques,  odontomes  coronaires,  odontomes  radiculaires. 

So  far  as  the  origin,  development,  and  pathology  of  the  odon- 
tomata are  concerned,  there  is  no  important  difiference  in  the  views 
held  by  Broca  and  Sutton.  The  teaching  of  Broca  upon  this  topic  may 
be  briefly  stated  as  follows : 

1st.  Odontomes  embryoplastiques.  These  are  tumors  which  are 
supposed  to  arise  from  the  membrana  eboris  before  the  development  of 

667 


668 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


the  odontoblastic  layer  of  the  dentin  papilla.  Their  development  takes 
place  at  a  period  when  there  has  not  yet  occurred  any  distinctive  differ- 
entiation of  cells  peculiar  to  tooth-structure.  They  are  derived  from 
embryonic  tissue,  and  contain  no  elements  which  would  mark  them  as 
being  of  dental  origin.  Their  structure  is  fibrous  or  fibroplastic,  and 
does  not  differ  from  tumors  of  this  character  found  in  other  locations 
of  the  body. 

Fig.  365. 


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Developing  Tooth. 


2d.  Odontonves  odontoplastiques.  This  form  of  odontome  arises 
from  the  layer  of  odontoblastic  cells  before  the  dentin  has  begun  to 
develop.  The  papilla  takes  on  an  irregular  growth,  and  the  tissue  so 
formed,  by  reason  of  the  presence  of  the  odontoblasts,  finally  becomes 
calcified,  presenting  characteristics  of  structure  more  or  less  like  true 
dentin ;  or  it  may  present  certain  elements  of  enamel  commingled  with 


ODONTOMATA. 


669 


thcni;  or  it  may  assume  the  form  of  a  mass  of  heterogeneous  dental 
tissues  in  no  way  resembling  a  tooth  in  external  outline.  Sometimes, 
as  a  result  of  the  destruction  of  the  odontoblasts,  the  tissue  may  resem- 
ble an  imperfect  bone  formation. 

3d.  Odontomcs  coronaires.  This  variety  of  odontome  develops 
during  the  formation  of  the  tooth,  after  a  cap  of  dentin  has  been  formed 
over  the  dentinal  papilla,  and  is  the  result  of  a  localized  hyperplasia. 
The  tumor  is  confined  to  the  crown  of  the  tooth,  and  no  matter  how 
much  the  tumor  may  be  changed  in  form  by  subsequent  hyperplasia, 
the  mass  still  bears  a  close  resemblance  to  normal  tooth-structure. 

4th.  Odontoiiies  radiculaires.  The  odontomes  of  this  class  are 
developed  during  the  formation  of  the  root  of  the  tooth,  after  the  crown 
has  been  completed,  and  are  the  result  of  a  general  hyperplasia  of  the 
dentinal  papilla  occurring  at  this  period.     These  tumors  are  confined  to 

Fig.  366. 


Epithelial  Odontome.— Natural  Size.     (Afier  Suiton.) 

the  roots  of  the  affected  tooth,  which  they  may  envelop.  The  char- 
acter of  the  tissue  in  the  cases  which  have  been  examined  is  dentin  and 
cementum. 

This  classification  of  Broca  has  been  almost  universally  adopted 
by  writers  upon  this  subject  ever  since  its  publication;  but  the  recent 
classification  of  Sutton  is,  in  the  opinion  of  the  writer,  the  more  accu- 
rate, and  gives  a  better  foundation  for  a  correct  understanding  of  the 
origin,  development,  and  pathology  of  these  growths,  and  will  there- 
fore be  followed  in  this  work.  The  writer,  however,  takes  the  liberty 
of  placing  the  epithelial  odontomes  (Fig.  366)  and  the  follicular  odon- 
tomes, on  account  of  their  character,  under  the  head  of  cysts,  and  of 
discussing  the  former  with  the  multilocular  cysts  (Fig.  367),  and  the 
latter  in  a  separate  chapter  under  the  head  of  Dentigerous  Cysts.  The 
other  forms  of  odontomes,  as  classified  by  Sutton,  are  productive  of 
solid  tumors  of  the  jaws,  and  will  be  considered  in  the  order  arranged 
by  that  author. 

Fibrous  Odontomes. — Odontomes  of  this  form  are  the  result  of 
excessive  growth  of  the  fibrous  capsule  which  invests  the  tooth-germ. 
This  capsule,  or  sac,  is  derived  from  the  connective  tissue  at  the  base  of 


670 


SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 


the  dentin  papilla,  and  invests  the  crown  of  the  developing  tooth.  The 
capsule  proper  consists  of  two  layers:  An  external  one,  consisting  of  a 
dense  fibrous  structure,  and  an  internal  one  composed  of  a  soft,  gel- 
atinous substance,  rich  in  connective-tissue  corpuscles,  and  containing 
some  true  fasciculi  of  connective  tissue.     (Kolliker.j 

The  tissues  composing  the  capsule  or  dental  sac,  under  certain 
conditions,  become  very  much  thickened  and  consolidated,  and  con- 
stitute, with  the  inclosed  tooth,  a  tumor  designated  as  a  fibrous  odon- 
tome. 

The  conditions  which  bring  about  this  thickening  and  consolida- 
tion of  the  dental  capsule  are  not  very  well  understood,  but  Sutton  is 
of  the  opinion  that  rickets  plays  an  important  part  in  the  causation  of 
the  disease,  from  the  fact  that  in  rickety  children  those  membranes  are 
most  affected  which  are  engaged  in  the  production  of  bone.     Tumors 

Fig.  2>^7. 


'---   '^rr 


'~5^ 


Microscopical  Character  of  an  Epithelial  Odqntome.    (After  Sutton.) 

of  this  character  are  frequently  mistaken  for  fibromata.  The  error  is 
most  likely  to  occur  in  those  cases  in  which  the  tooth  is  small  or 
imperfectly  developed.  Microscopically  the  fibrous  elements  are  found 
to  be  arranged  in  laminae,  with  strata  of  calcareous  material.  (Sutton.) 
(Fig.  368.)  These  tumors  are  not  confined  to  the  human  species,  but 
are  quite  common  in  certain  of  the  lower  animals,  principally  in  the 
mammalia.  The  ruminants  are  most  frequently  affected  with  the  dis- 
ease, particularly  goats. 

Heath  removed  two  tumors  of  this  character  from  a  boy  seven 
and  one-half  years  old,  which  developed  symmetrically  in  the  angles 
of  the  lower  jaw.  These  tumors  were  covered  by  a  thin  layer  of 
compact  bone-tissue.  The  boy  had  suffered  from  rickets,  but  at  the 
time  of  the  operation  was  well  nourished. 

Cementomes. — Cementomes  are  the  result  of  calcification  of  the 
thickened  and  enlarged  tooth-capsule,  which  eventually  leaves  the 
tooth  imbedded  in  a  mass  of  ossific  matter.     Odontomes  of  this  char- 


ODONTOMATA. 


671 


acter  are  most  frequently  seen  in  the  horse.  Occasionally  they  are 
seen  in  the  human  subject.  The  tissue  of  which  the  tumor  is  com- 
posed is  apparently  a  modified  cementum.  It  is  arranged  m  lammae 
similar  to  the  laminated  structure  of  the  fibrous  odontome.      They 

Fig.  .-^68. 


M  A  Goat.-Natural  Size.     (After  Sutton.) 


Fibrous  Odontome  fro 

sometimes  attain  a  very  large  size.  Tomes  described  an  odontome  of 
tliis  character,  removed  from  the  jaw  of  a  horse,  which  weighed  ten 
ounces.  Sutton  has  given  an  account  of  another  wh.ch  weighed 
twenty-five  ounces.    In  this  mass  of  tissue  there  could  be  observed 

Fig.  369. 


„^>,  A  HoRSF— Half  Natural  Size.    (After  Sutton.) 
Cementome  from  a  horse.    riALi^  ii«.iu 


the  outlines  of  three  teeth  imbedded  in  the  cementum.  (Fig.  369-) 
The  largest  cementome  ever  recorded  up  to  the  present  time  weighed 
seventy  ounces;  this  specimen  is  preserved  in  the  Royal  Vetermary 

Collesre,  London.  ^      ^,  .  ^^  ^ 

Through  the  kindness  of  Professor  Sayer,  of  the  Chicago  Veter- 


672  SURGERY    OF   THE    FACE,    MOUTH,   AND   JAWS. 

inary  College,  the  writer  has  been  permitted  to  examine  and  photo- 
graph an  enormous  cementome  taken  from  a  female  colt  two  years  of 
age,  post-mortem,  which  weighed  in  the  moist  state  ninety-six  ounces, 
and  in  its  present  dried  state  fifty-nine  ounces.  It  measures  through 
its  longest  diameter  five  and  three-fourths  inches;  through  its  shortest 
diameter,  four  and  one-fourth  inches;  its  largest  circumference  is  six- 
teen and  one-fourth  inches,  and  its  smallest  circumference  fourteen 
and  three-fourths  inches.  The  tumor  was  located  in  the  right  superior 
maxilla,  and  was  first  discovered  when  the  animal  was  about  five 
months  old.  It  grew  very  rapidly,  producing  extensive  inflammation 
of  the  jaw,  with  abscess,  which  constantly  discharged  through  several 
sinuses.     Death  resulted  from  inability  to  take  food. 

Fig.  370. 


Cementome  from  Young  Horse. — Reduced  One-half  Natural  Size. 


The  growth  upon  its  external  surface  is  lobulated,  the  base  being 
made  up  of  numerous  irregular  lobes.  (Fig.  370.)  On  section 
through  its  longest  diameter,  which  intersected  its  base,  it  appeared  to 
be  a  homogeneous  mass  of  cementum,  containing  an  irregular  cavity 
in  its  center,  surrounded  by  an  area  of  spongy-looking  tissue,  similar 
to  the  cancellated  tissue  of  bone.  (Fig.  371.)  This  cavity  has  the  same 
appearance  as  the  pus-cavities  sometimes  found  in  the  tusks  of  ele- 
phants. On  closer  inspection  a  distinct  laminated  structure  can  be  seen 
at  the  periphery  of  the  tumor,  which  appears  to  be  as  dense  as  ivory. 
After  the  most  critical  inspection  it  was  not  possible  to  discover  any 
evidence  of  a  tooth  or  even  a  suggestion  of  tooth-formation.  At  the 
base  of  the  tumor  there  is  a  large  depression  or  excavation,  which  has 
the  appearance  of  having  been  the  resting-place  of  a  molar  tooth. 

(Fig.  372.) 

Compound  Follicular  Odontomes. — This  form  of  odontome  is  the 

result,  according  to  Sutton,  of  a  "sporadic  calcification  of  the  thick- 


ODONTOMATA. 


673 


ened  and  enlarged  tooth-capsule,"  while  in  the  formation  of  cemen- 
tomes  the  process  of  calcification  takes  place  en  masse.  By  this  spo- 
radic calcification  of  the  capsule  there  is  developed  within  the  tumor 


Fig. 


Vertical  Section  through  the  Center  of  Fig.  370.    Reduced  One-Half  Natural  Size. 

"a  number  of  small  teeth  or  denticles,  consisting  of  cementum  or 
dentin,  or  even  ill-shaped  teeth  composed  of  the  three  dental  elements 
— cementum,  dentin,  and  enamel."     (Sutton.) 

Fig.  S72. 


Vertical  Section  through  the  Center  of  Fig.  370,  Opposite  Half.— Reduced  One-half 

Natural  Size. 


The  writer  is  inclined  to  the  opinion  that  the  explanation  of  the 
presence  of  nests  of  teeth  or  denticles  in  such  tumors  is  that  the  epithe- 
lial elements  confined  within  the  tooth-capsule  break  up,  as  is  the  case 
with  the  epithelial  cord,  into  minute  masses,  which  under  favorable 
conditions  assume  shapes  similar  to  the  normal  teeth,  but  smaller  in 

44 


674  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

size,  or  ill-shaped  teeth,  or  masses  of  tissue  of  heterogeneous  structure 
which  have  no  definite  outline. 

These  tumors  have  been  observed  in  the  human  subject,  and  in 
goats,  horses,  and  other  mammalia.  In  man  they  usually  develop  in 
early  life,  during  the  period  of  second  dentition.  Among  the  records 
of  cases  of  this  character,  the  youngest  was  a  boy  ten  years  old  and 
the  eldest  a  woman  of  twenty-seven  years. 

The  number  of  denticles  found  in  tumors  of  this  character  varies 
greatly.  From  three  or  four  to  as  many  hundreds  have  been  removed 
from  the  jaws  of  a  single  patient. 

Among  the  recorded  cases  of  special  interest  which  will  be  briefly 
mentioned  are  the  following: 

Tellander  reported  a  case  of  tumor  of  the  right  side  of  the  supe- 
rior maxilla  in  a  woman  twenty-seven  years  of  age,  which  had  been 
growing  since  she  was  twelve  years  old.  The  character  of  this  growth 
was  a  hard,  painless  swelling.  It  occupied  the  space  in  which  should 
have  been  located  the  first  molar,  the  bicuspids,  and  the  cuspid  of  the 
permanent  set.  These  teeth  had  not  erupted.  Upon  opening  the 
tumor  it  was  found  to  contain  several  minute  teeth;  nine  individual 
teeth  with  conical  crowns  and  conical  roots,  each  complete  in  itself, 
the  crown  being  furnished  with  enamel;  and  six  masses  of  dental  tis- 
sues having  the  appearance  of  being  formed  by  a  union  of  several 
single  teeth,  and  all  presenting  the  characteristics  of  supernumerary 
teeth.  Another  tooth  made  its  appearance  about  a  year  later  in  the 
location  from  which  the  tumor  was  removed. 

Another  case,  recorded  by  Windle  and  Humphreys,  which  oc- 
curred in  the  practice  of  Sims,  of  Birmingham,  England,  was  found 
in  the  mouth  of  a  boy  ten  years  of  age.  The  lateral  incisor  and  cuspid 
of  the  permanent  teeth  had  not  made  their  appearance,  and  this  space 
was  occupied  by  a  tumor  with  hard,  unyielding  walls,  from  which  were 
taken  forty  small,  irregularly-formed  denticles. 

Tomes  has  recorded  a  case  in  a  Hindoo,  aged  twenty,  having  a 
tumor  of  this  character  located  in  the  front  of  the  mouth,  and  for  whom 
Mathias  removed  fifteen  masses  of  ill-formed  and  united  super- 
numerary teeth  and  bone.  The  deformity  of  the  jaw  rapidly  disap- 
peared after  the  removal  of  the  supernumerary  dental  tissues.  The 
only  peculiarity  that  could  be  noticed  later  was  the  absence  of  the 
central  and  lateral  incisors.     (Fig.  373.) 

The  writer  has  recorded  a  case  in  the  chapter  on  Dentigerous 
Cysts  from  which  five  small  teeth  or  denticles  were  removed. 

The  most  remarkable  case  of  "abnormal  development  of  the  teeth 
forming  tumors  of  the  jaw"  has  been  reported  by  O.  Hildebrand,  of 
Gottingen.  "A  child  twelve  years  of  age  had  suffered  from  enlarge- 
ment and  tumefaction  of  the  jaws,  resulting  from  an  excessive  develop- 


ODONTOMATA. 


675 


ment  of  teeth,  she  having  submitted,  in  1889,  to  several  operations, 
and  been  relieved  of  between  one  hundred  and  fifty  and  two  hundred 
teeth  of  various  sizes  and  forms.  In  July,  1891,  the  patient  presented 
again  for  operation,  the  lower  jaw  being  much  thickened  upon  both 
sides,  and  also  the  right  upper  jaw.  Seventeen  teeth  were  found,  part 
of  them  normally  developed,  others  in  an  imperfectly  developed  con- 
dition and  very  irregular  in  position.  From  the  upper  and  lower 
jaws  several  masses  of  teeth  were  again  removed,  and  represented 
about  one  hundred  and  fifty  teeth  in  conformation  like  those  previously 

Fig.  T,y2,- 


A,  Denticles  from  Tellander's  Case.    Total  number,  twenty-eight. 

B,  Denticles  from  Sims's  Case.    Total  number,  forty. 

C,  Denticles  from  Mathias's  Case.    Total  number,  fifteen. 

(After  Sutton.) 


removed,  making  in  all  between  three  hundred  and  fifty  and  four  hun- 
dred. Two  round,  glassy  bodies  were  also  found,  each  about  the  size 
of  two  peas,  which  were  composed  of  tooth-structure,  as  revealed  by 
the  microscope.  The  writer  of  the  report  was  of  the  opinion  that 
tooth-formation  would  continue,  in  all  probability,  until  the  epithelial 
tissues  of  the  mucous  membrane  covering  the  jaws  had  reached  their 
final  development."     (Matas.) 

Sutton  describes  a  case  of  this  character  occurring  in  a  Hima- 
layan goat  which  had  a  tumor  in  each  upper  jaw.  "The  interior  of 
each  tumor  was  occupied  with  teeth,  denticles,  and  fragments  of  ce- 
mentum,  varying  in  size,  numbering  in  all  three  hundred.     Many  were 


676  SURGERY    OF    THE    FACE,    MOUTH,    AND   JAWS. 

firmly  imbedded  in  the  fibrous  walls  of  the  tumor,  whilst  those  which 
were  free  in  the  sac  had  become  loosened  by  suppuration." 

Logan  has  recorded  a  similar  case  occurring  in  the  maxilla  of  a 
horse,  which  contained  four  hundred  small,  ill-formed  teeth  or  den- 
ticles. 

Radicular  Odontomes. — These  tumors  are  located  upon  the  roots 
of  the  teeth,  and  are  due  to  excessive  growth  of  the  formative  pulp 
after  the  development  of  the  crown  has  been  completed,  and  while  the 
root  is  in  process  of  formation.  They  appear  in  the  form  of  enlarge- 
ments upon  the  root,  which  they  may  completely  imbed,  and  some- 
times reach  a  size  many  times  larger  than  the  tooth  itself.  The  growth 
causes  little  change  in  the  character  of  the  tooth  or  of  its  roots. 

The  tissues  which  make  up  the  tumor  are  dentin  and  cementum; 
enamel  does  not  enter  into  its  formation,  for  the  reason  that  the 
enamel-organ  has  performed  its  function  and  been  calcified  some  time 
prior  to  the  formation  of  the  root  of  the  tooth.  The  principal  functions 
of  the  formative  pulp  and  the  follicle  or  sac  are  the  production  of  dentin 
and  cementum;  these  functions  become  abnormally  stimulated,  for 
some  reason  not  understood,  with  the  result  of  producing  an  enlarged 
or  hypertrophied  condition  of  these  tissues.  The  pulp  is  large  and 
sometimes  calcified. 

Salter,  in  his  description  of  this  class  of  tumors,  terms  them  hernia 
of  the  fang,  and  regards  them  as  outgrowths  due  to  hypertrophy  and 
dilatation  of  the  root  of  the  tooth.  He  also  thinks  that  the  term 
applied  to  this  form  of  tumor  by  Broca,  odontome  radiculaire,  is  objec- 
tionable, from  the  fact  that  it  carries  with  it  no  meaning  beyond  that 
of  location,  and  is  equally  applicable  to  other  tumors.  They  have  been 
found  in  both  the  upper  and  the  lower  jaw.  This  form  of  odontome 
is  exceedingly  rare  in  the  human  subject,  only  a  very  few  ever  having 
been  removed,  the  principal  ones  being  those  of  Forget,  Tomes, 
Heider,  Wedl,  and  Salter. 

The  one  described  by  Forget  occurred  in  the  practice  of  M. 
Maisonneuve,  and  consisted  of  a  large  tumor  about  the  size  of  a  ban- 
tam's tgg,  which  was  attached  to  the  distal  surface  of  a  left  lower 
molar  tooth,  involving  the  neck  and  a  large  part  of  the  root.  The 
tumor  caused  considerable  disfigurement  of  the  face.  In  an  effort  to 
extract  the  tooth  the  tumor  came  away  attached  to  it.  The  patient 
was  a  man  forty  years  of  age. 

The  second  example  was  described  by  Tomes,  the  specimen,  which 
is  the  largest  ever  seen  in  the  human  subject,  having  been  presented 
by  Hare.  It  was  removed  from  the  upper  jaw  of  a  man  forty-one  years 
of  age.  The  tumor  had  been  growing  for  several  years,  and  finally 
caused  suppuration,  with  perforation  of  the  cheek.  The  growth  is  a 
large,  lobulated  mass  connected  with  the  roots  of  an  upper  molar  tooth, 
and  four  or  five  times  as  large  as  the  tooth  itself.     (Fig.  374.) 


ODONTOMATA. 


677 


Heider  and  Wedl  briefly  mentioned  a  case  in  many  respects  like 
the  one  just  described.  In  this  case  the  second  molar  tooth  of  the 
right  side  had  developed  into  a  large,  irregular  mass,  which  held  down 


Fig.  374. 


Radicular  Odontome. — Natural  Size.    (After  Sir  John  Tomes.) 

Fig.  375. 


Radicular  Odontome  from  Human  Subject.— A,  Natural  Size  of  the  Specimen. 

(After  Salter.) 

Fig.  376. 


Radicular  Cementome  from  Man  aged  Twenty-five  Years.     (After  Sutton.) 

the  third  molar.  The  fourth  example  occurred  in  the  practice  of 
Heath,  and  formed  the  subject  of  a  classic  paper  by  Salter,  This  spec- 
imen consisted  of  a  rather  small  lower  molar  tooth,  to  the  distal  root 


678  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

of  which  is  attached  a  large,  lobulated  tumor  more  than  twice  the  size 
of  the  tooth.  (Fig.  375.)  The  outer  layer  of  this  mass  is  composed 
of  cementum;  within  this  is  a  stratum  of  dentin,  and  the  center  is  occu- 
pied by  a  calcified  tooth-pulp,  the  latter  being  formed  of  a  "confused 
mass  of  bone-structure  and  dentin-structure  surrounding  a  vascular 
net-work  of  the  same  character  of  the  dejntinal  pulp."     (Heath.) 

Windle  and  Humphreys  have  described  a  case  obtained  from  a 
man  twenty-five  years  of  age.  The  odontome  was  situated  in  the 
lower  jaw,  in  the  region  of  the  right  second  molar  tooth.    (Fig.  376.) 

These  tumors  are  much  more  frequent  in  the  lower  animals  than 
in  man.  In  the  other  mammalia  they  are  often  multiple.  Rodents 
are  especially  liable  to  them,  on  account,  no  doubt,  of  the  fact  that  their 
teeth  grow  from  persistent  pulps.  (Sutton.)  They  have  been  found 
in  marmots,  porcupines,  and  agoutis.  The  largest  odontomes  have 
been  found  associated  with  the  roots  of  the  tusks  of  elephants. 


Composite  Odontome  from  Young  Steer. — Reduced  One-hai.f  Natural  Size. 

Composite  Odontomas. — This  term  is  applied  by  Sutton  to  all 
those  hard  tooth-tumors  which  lack  the  form  of  teeth,  but  are  found 
in  the  jaws,  and  consist  of  a  heterogeneous  mass  of  enamel,  dentin, 
and  cementum.  This  form  of  odontome  is  the  result  of  an  abnormal 
growth  of  all  the  elements  which  compose  the  dental  germ, — enamel- 
organ,  formative  pulp,  and  sac  or  follicle. 

Salter  applies  the  term  "warty  teeth"  to  this  form  of  odontome. 
Broca  designates  them  as  odontomes  coronaires. 

These  tumors  are  often  found  to  be  composed  of  two  or  more 
tooth-germs  fused  together  in  an  indiscriminate  manner.  They  can 
be  differentiated  from  the  cementomes  in  which  two  or  more  teeth  are 
united  together  by  the  fact  that  in  the  composite  odontome  the  various 
tissues  form  a  heterogeneous  mass,  while  in  the  cementomes  the  form 
of  each  tooth  can  be  readily  defined.     (Sutton.) 

The  composite  odontomata  have  seemed  to  be  confined  to  man,  as 
no  cases  up  to  the  present  time  have  been  recorded  as  occurring  in  the 
lower  animals.  Fig.  377  is  a  composite  odontome  removed  from  the 
jaw  of  a  young  steer  which  had  died  from  extensive  suppuration  and 


ODONTOMATA.  679 

necrosis  of  the  lower  jaw.  The  disease  was  found  to  have  been  caused 
by  the  presence  of  this  growth,  which  appears  to  be  a  fusion  of  two 
molar  teeth  making  an  irregular  mass  of  dental  tissues.  They  are 
found  in  the  human  subject  in  both  the  upper  and  lower  maxillae;  the 
majority  of  the  reported  cases,  however,  have  been  located  in  the  lower 
jaw.  Sutton  is  of  the  opinion  that  many  cases  of  reported  exostosis  of 
the  antrum  were  really  composite  odontomes,  and  cites  the  case  of  M. 
Michon,  who  removed  a  large  tumor  from  the  antrum  of  a  young  man 
aged  nineteen  years,  which  was  described  as  an  exostosis,  but  which  in 
reality  was  a  composite  odontome,  as  proved  by  the  report  which 
accompanied  it  of  its  microscopical  structure.     (Fig.  3/8.)     This  con- 

FiG.  378. 


Odontome  from  the  Superior  Maxii.la.— Natural  Sizii.     (Michoii,  after  Sutton.) 

sisted  of  "tissue  presenting  many  parallel  tubules  having  the  appear- 
ance of  exaggerated  dentinal  tubes."  Duka  reported  a  similar  case 
occurring  in  a  Mahometan  woman  twenty-six  years  of  age,  in  which 
the  tumor  was  located  in  the  right  antrum.     (Fig.  379.) 

The  diagnosis  of  these  tumors  is  often  a  difficult  matter.  The 
following  case,  occurring  in  the  practice  of  Heath,  and  related  by  him 
in  his  "Injuries  and  Diseases  of  the  Jaws,"  illustrates  the  difficulties 
experienced  in  diagnosing  the  odontomata.  "Miss  C,  aged  eighteen 
years,  was  brought  to  me  in  July,  1881,  with  a  considerable  swelling 
of  the  right  side  of  the  lower  jaw,  some  of  which  was  evidently  inflam- 
matory, and  partly  the  result  of  previous  treatment;  but  there  was,  I 
thought,  sufficient  evidence  of  expansion  of  the  jaw  to  .warrant  the 
opinion  that  a  tumor  was  present,  and  I  therefore  recommended  the 
removal  of  a  portion  of  the  jaw.     Suppuration  was  then  present,  and 


68o 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


with  the  finger  a  rough  surface  of  apparently  exposed  bone  could  be 
felt,  but  this  I  regarded  as  the  result  of  inflammatory  action  excited 
by  the  injudicious  irritation  of  a  periosteal  growth,  since  partial  ne- 
crosis of  a  jaw  involved  by  cartilaginous  or  malignant  growths,  which 
have  been  irritated  by  exploratory  measures,  is  in  my  experience  by 
no  means  common.  The  patient  had  the  advantage  of  the  opinion  of 
Sir  James  Paget,  who  was  not  perfectly  satisfied  as  to  the  existence 
of  a  tumor,  and  expressed  a  hope  that  the  case  might  prove  to  be  one 
of  necrosis.  Under  these  circumstances  the  operation  was  postponed. 
"On  my  return  to  town  in  September  I  found  the  patient  improved 
in  health,  and  the  swelling  diminished  by  the  subsidence  of  the  inflam- 
mation, but  a  considerable  enlargement  of  the  lower  jaw  was  still 
present,  with  a  sinus  opening  externally.     From  the  mouth  a  white 

Fig    ^^79 


Composite  Odontome  from  the  Superior  Maxilla.— Natural  Size.     (Duka,  after  Sutton.) 


mass  was  visible,  which,  appearing  among  granulations,  looked  like 
necrosis,  and  I  agreed  that  an  attempt  should  be  made  to  remove  this, 
although  I  could  not  think  it  accounted  for  the  expansion  of  the  jaw. 
Under  chloroform  I  proceeded  to  examine  the  mouth  with  my  finger. 
I  soon  found  that  the  white  mass  was  not  bone,  but  tooth,  and  yet  was 
unable  to  make  out  its  outline.  I  was  unable  to  make  any  impression 
with  a  chisel  or  gouge,  but  at  last  with  an  elevator  succeeded  in  lifting 
out  of  its  bed  a  mass  of  dental  structures,  which  measured  one  and  one- 
half  inches  antero-posteriorly,  one  inch  transversely,  and  one  and  one- 
fourth  inches  from  above  downward.  It  weighed  three  hundred  and 
fifteen  grains."  (Fig.  380.)  The  specimen  was  placed  in  the  hands  of 
C.  Tomes  for  microscopic  and  histologic  examination,  and  was  found 
to  be  composed  of  a  conglomerate  mass  of  enamel,  dentin,  and  osteo- 
dentin. 

The  most  remarkable  example  of  a  composite  odontome  is  the 


ODONTOMATA. 


68 1 


classic  case  of  Forget.  This  occurred  in  the  person  of  a  young  man 
aged  twenty  years,  who  presented  himself,  in  1855,  with  disease  of  the 
lower  jaw,  from  which  he  had  sufifered  since  he  was  five  years  of  age. 
The  tumor  consisted  of  a  large,  round,  smooth,  hard,  unyielding  swell- 
ing, which  occupied  nearly  the  whole  of  the  left  side  of  the  lower  jaw. 
The  teeth  posterior  to  the  first  bicuspid  were  absent.     The  tumor  was 


Composite  Odontome  from  Young  Lady  aged  Eighteen.    (After  Heath  ) 


removed  by  dividing  the  jaw  in  front  of  the  first  bicuspid  and  through 
the  ascending  ramus  on  a  line  with  the  inferior  dental  foramen.  The 
tumor  when  removed  proved  to  be  a  hard  oval  mass  the  size  of  an  egg, 
having  an  uneven  surface,  in  places  covered  with  small  tubercles,  which 
were  coated  with  enamel.     The  tumor  had  formed  for  itself  a  large 


Composite  Odontome— Natural  Size.     (After  Forget.) 


cavity  in  the  jaw,  which  extended  from  the  first  bicuspid  to  the  ramus. 
(Fig.  381.)  The  microscopic  examination  of  the  tumor  showed  it  to 
be  Composed  mainlv  of  dentin,  in  places  covered  with  enamel  which 
dipped  down  in  the  crevices,  while  in  the  bottom  of  the  crevices  cemen- 
tum  was  found.  The  origin  of  the  tumor  was  the  fusion  and  hyper- 
trophv  of  the  last  two  molars.     Heath  gives  a  description  of  six  other 


682 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


cases  of  this  form  of  odontome  which  he  has  found  recorded.  Fig-.  382 
is  a  microscopic  section  of  an  odontome  found  in  the  jaws  of  a  full- 
term  human  fetus  which  was  otherwise  malformed.  The  case  is  inter- 
esting from  the  fact  that  it  must  be  an  exceedingly  rare  condition  in  a 
child  at  birth,  as  the  writer  has  been  unable  to  find  a  like  case  upon 
record. 

Fig.  382. 


Composite  Odontome — Transverse  Section— from  a  Full-Term  Human  Fetus. — Magnified. 

Diagnosis. — The  diagnosis  of  the  odontomata  is  sometimes  a 
matter  of  considerable  difficulty,  for  the  reason  that  the  symptoms  are 
usually  very  obscure,  and  those  which  are  prominent  are  often  leading 
symptoms  in  other  affections,  as,  for  instance,  in  the  Hhrous  odontomes, 
which  may  be  readily  mistaken  for  myeloid  sarcoma;  or  the  ce- 
mentomes  or  composite  odontomes  may  be  taken  for  exostosis,  and  in 
others,  when  suppuration  is  present,  for  necrosed  bone. 

Sutton  says,  'Tt  is  a  curious  fact  that  up  to  this  date  there  is  no 
instance  on  record  in  which  an  odontome,  other  than  a  follicular  cyst, 
has  been  diagnosed  before  operation."  In  all  doubtful  cases  of  tumors 
of  the  jaws,  occurring  in  youths  and  young  adults,  the  absence  in  the 


ODONTOMATA.  683 

location  of  the  tumor,  of  teeth  which  are  commonly  erupted  before  the 
age  at  which  the  tumor  began  to  grow,  should  excite  suspicion  that  the 
missing  teeth  are  the  cause  of  the  tumor,  and  an  exploratory  incision 
should  be  made  to  ascertain  this  fact  before  a  more  extended  or  serious 
operation  is  decided  upon. 

The  general  character  of  these  tumors  might  be  more  readily 
ascertained  and  differentiated  from  necrosed  bone-tissue  by  the  use  of 
steel  probes  with  sharp  points  instead  of  the  silver  probe  so  generally 
employed.  The  writer  feels  positive,  from  his  experience  in  other 
lines  where  it  has  been  necessary  to  differentiate  between  necrosed 
bone  and  an  unerupted  tooth,  that  many  of  the  errors  in  diagnosis  in 
cases  of  this  character  might  be  obviated  by  the  use  of  a  steel  instead 
of  a  silver  probe,  for  the  sensation  which  is  conveyed  through  the  steel 
instrument  in  contact  with  bone  or  with  tooth-structures  is  so  different 
from  that  conveyed  by  silver,  that  when  once  experienced  by  the  care- 
ful observer  it  will  always  thereafter  be  recognized.  The  writer  was 
recently  consulted  in  relation  to  an  obscure  case  of  disease  of  the  angle 
of  the  lower  jaw  in  a  married  lady  fifty  years  of  age,  who  had  up  to  one 
year  ago  enjoyed  uninterrupted  good  health.  The  disease  began  by  a 
painful  swelling  and  enlargement  of  the  left  side  of  the  lower  jaw  in  the 
region  of  the  third  molar  tooth.  This  tooth,  which  was  sound,  became 
very  sore  and  loose,  and  was  extracted  by  the  family  dentist  upon  the 
supposition  that  the  disease  was  alveolar  abscess.  On  removing  the 
tooth  a  considerable  discharge  of  pus  took  place.  The  swelling  and 
enlargement  of  the  jaw  steadily  progressed,  from  this  time,  with  pain 
and  a  constant  discharge  of  pus.  The  second  molar  had  sometime 
afterward  been  removed  and  the  cavity  curetted,  and  this  was  followed 
by  the  exfoliation  of  several  small  pieces  of  necrosed  bone.  She 
next  consulted  an  eminent  surgeon,  who  thought  it  a  case  of  necrosis, 
and  operated  twice  by  cutting  into  the  jaw  through  an  external  incision 
and  removing  considerable  portions  of  the  cancellated  structure  of  the 
bone.     Six  weeks  afterward  the  discharge  had  not  abated. 

The  conditions  at  the  time  of  the  consultation  were  as  follows: 
An  opening  one  and  one-half  inches  in  length  existed  in  the  soft  -tissues 
and  the  jaw,  just  in  front  of  the  angle  and  at  the  lower  border  of  the 
bone.  This  opening  went  entirely  through  the  bone  and  communi- 
cated with  the  cavity  of  the  mouth  at  the  alveolar  border,  which  was 
greatly  thickened  at  this  location.  Careful  exploration  of  the  wound 
cavity  in  the  body  of  the  jaw,  with  a  sharp-pointed  steel  probe,  revealed 
the  presence  of  a  body  more  dense  than  the  surrounding  bone,  and 
located  well  under  the  ascending  ramus.  Upon  further  examination 
certain  dense  surfaces  could  be  felt  which  gave  the  assurance  of  being 
dental  tissue.  So  sure  did  the  writer  feel  that  there  could  be  no  mis- 
take as  to  the  presence  of  such  a  body  in  this  location,  that  he  made  an 


684 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


unqualified  diagnosis  of  an  odontome  and  advised  an  immediate  opera- 
tion. The  operation  consisted  of  cutting  away  the  bone  from  around 
the  tumor  with  gouge,  chisel,  and  mallet — this  was  done  through  the 
mouth — and  the  tumor  then  lifted  from  its  bed  in  the  jaw  by  means  of 
an  elevator  and  the  external  wound  closed.  Fig.  383  is  a  photograph 
of  the  odontome,  natural  size.  The  character  of  the  growth  would 
class  it  as  a  composite  odontome.  Rapid  improvement  took  place 
after  the  operation,  and  at  the  end  of  six  weeks  the  patient  was  dis- 
charged cured. 

Fig.  383. 


Composite  Odontome. 


-Natural  Size. — P'rom  Lower  Maxilla  of  a  Woman  Fifty 
Years  of  Age. 


Fig.  384  shows  another  odontome  removed  from  the  jaw  of  a  lady 
about  forty  years  of  age,  by  my  friend.  Dr.  Mark  F.  Finley,  Washing- 
ton, D.  C.  The  specimen  is  now  in  the  Army  Medical  Museum,  Wash- 
ington, D.  C. 

Prognosis. — The  prognosis  of  odontomata  is  favorable.  Opera- 
tion is  always  required  for  their  removal,  though  Heath  mentions  a 
case  recorded  by  Harrison  in  which  the  odontome  was  spontaneously 
expelled.  Sutton  mentions  two  cases;  the  first  is  recorded  by  Hilton 
in  Guy's  Hospital  Reports.  This  was  the  largest  odontome  that  has 
been  known  to  form  in  the  human  antrum.  It  weighed  nearly  fifteen 
ounces.  (Fig.  385.)  The  patient  was  thirty-six  years  old.  The  dis- 
ease was  first  noticed  thirteen  years  before:  the  cheek  swelled,  the  eye 
was  displaced  from  the  orbit  and  finally  burst.  The  cheek  sloughed 
away  later,  leaving  the  growth  exposed.  Suppuration  was  profuse, 
accompanied  by  necrosis  of  the  bone.  The  tumor  finally  dropped  out, 
leaving  an  enormous  hole  in  his  face.  Section  of  the  odontome 
showed  it  to  be  a  laminated  structure.     (Fig.  386.) 


ODONTOMATA. 

Fig.  384. 


Odontome.     (Army  Medical  Museum:  Dr.  Finley.) 


Fig.  .385. 


Large  Odontome  spontaneously  shed  from  the  Antrum  ;  Weight  nearly  Fifteen 
Ounces.     (Hilton,  after  Sutton.) 


686 


SURGERY  OF  THE  FACE,  MOUTH,  AND  JAWS. 


The  second  case  is  recorded  by  Parker  as  occurring  in  a  young 
lady  aged  nineteen  years.  The  growth  was  attached  to  the  left  second 
molar.  In  an  effort  to  extract  the  tooth  it  broke,  leaving  the  tumor 
behind.  Subsequent  attempts  were  made  to  extract  it,  but  without 
.success.     Two  years  later  it  was  spontaneously  expelled  from  the  jaw. 

(Fig.  387-) 

Treatment. — The  removal  of  the  various  forms  of  odontomata  as 
a  rule  does  not  require  an  extensive  operation.  If  they  can  be  diag- 
nosed before  operation,  the  matter  becomes  one  of  simple  enucleation. 
Everv  effort  should  be  made,  in  the  treatment  of  these  tumors,  to 


Fig.  .386. 


Section  of  the  Odontome  Fig.  3S5.  Shov.inc  tks  Concentric  L.a.mination. 
( Hilton,  after  Sutton. ) 

Fig.  38/- 


Odontome.— X.A.TUR-A.L  Size.     (Parker,  after  Suiton.) 


extract  the  growth  without  removing  any  extensive  portion  of  the 
bone.  This  in  some  cases  may  not  be  possible,  and  a  considerable 
portion  of  the  bone  must  be  sacrificed;  but  it  would  seem,  from  a  study 
of  the  reported  cases,  that  in  every  one  in  which  a  portion  of  the  body 
of  the  bone  had  been  removed  with  the  tumor,  this  serious  operation 
might  have  been  avoided  but  for  the  difffculties  of  diagnosis.  Heath 
says,  "Where  the  growth  is  presumably  connected  with  a  tooth,  the 
rule  of  removing  all  neighboring  teeth  which  may  possibly  be  con- 
nected with  it  should  be  invariably  followed  before  any  more  serious 
operation  is  undertaken." 

After  the  enucleation  of  the  tumor,  the  cavity  may  be  packed  for 
a  few  days  with  boric  acid  gauze,  and  allowed  to  close  by  granulation. 


CHAPTER    LXV. 

ODONTOMATA  (Continued). 

In  the  preceding  chapter  upon  the  Odontomata,  those  forms  of 
odontomes  were  described  which  had  their  origin  in  some  form  of 
aberration  in  development.  The  maxillary  bones,  however,  are  occasion- 
ally the  seat  of  tumors  which  arise  from  aberration  in  the  position  of  the 
teeth.  These  growths  are  not  included  in  the  classification  of  either 
Broca  or  Sutton. 

Irregularities  in  the  position  of  the  germs  of  the  teeth  are  some- 
times of  such  a  nature  as  to  prevent  their  eruption,  and  thereby  cause 
the  production  of  tumors. 

Tumors  arising  from  this  cause  have  seldom  been  observed  in 
connection  with  the  deciduous  teeth,  for  the  reason  that  irregularities 
in  either  development  or  position  are  very  rarely  associated  with  these 
teeth.  The  period  covered  by  second  dentition  is  the  age  at  which 
these  tumors  are  most  likely  to  be  developed,  the  most  active  stage  of 
this  function  being  the  time  when  they  most  frequently  appear.  But 
it  is  not  at  all  uncommon  for  individuals  past  middle  life  to  be  the  sub- 
jects of  such  growths. 

These  tumors  are  associated  with  teeth  which  by  reason  of  their 
malposition  in  the  jaws  are  unable  to  emerge  from  the  crypts  in  which 
they  have  been  developed.  As  a  result,  there  is  in  certain  cases  a 
tendency,  due  to  the  irritation  produced  by  the  malposition  of  the 
tooth,  to  the  formation  of  a  tumor,  sometimes  of  a  cystic  nature,  as  in 
dentigerous  cysts,  or  a  dense,  osseous  growth,  which  appears  to  be  a 
thickening  or  hyperplasia  of  the  overlying  bone-tissue,  resembling  an 
osteoma  with  a  tooth  in  its  center.  The  teeth  found  in  these  tumors 
are  in  various  stages  of  development. 

The  solid  tumors  of  the  jaws  resulting  from  aberrations  in  the 
position  or  the  development  of  the  teeth  are  many  times  exceedingly 
difficult  to  correctly  diagnose,  their  character  often  remaining  con- 
cealed until  after  an  operation  has  been  made  for  their  removal.  Some 
of  the  very  best  surgeons  have  been  misled  in  their  diagnosis  of  these 
tumors,  and  have  made  extensive  and  needlessly  severe  operations 
under  the  belief  that  the  growth  was  an  osteoma  or  an  osteo-sarcoma. 
Sir  William  Fergusson  made  a  mistake  of  this  character  in  1856, 

6S7 


688  SURGERY    OF    THE    FACE,    MOUTfl,    AND    JAWS. 

in  removing  a  large,  dense  tumor  of  the  superior  maxilla  of  a  girl 
thirteen  years  of  age.  On  dividing  the  tumor  after  its  removal,  it  was 
found  to  contain  a  tooth  imbedded  in  its  center,  and  which  was  un- 
doubtedly the  cause  of  the  growth. 

The  deviations  in  the  position  of  the  unerupted  teeth  which  may 
cause  solid  tumors  of  this  character  may  be  classed  under  two  heads: 
I  St,  those  contained  within  the  alveolar  process;  2d,  those  situated  in 
other  and  sometimes  remote  portions  of  the  maxillary  bones. 

Causes. — The  teeth  which  are  most  liable  to  occupy  malpositions 
in  the  jaws  and  cause  the  formation  of  tumors  are  the  superior  and 
inferior  third  molars,  and  the  superior  cuspids.  Occasionally  the  su- 
perior first  and  second  molars,  the  superior  central  and  lateral  incisors, 
and  the  bicuspids  are  misplaced  in  the  jaws.  The  absence  of  a  certain 
tooth  from  its  position  in  the  affected  side  of  the  jaw,  and  in  which 
there  is  no  history  of  its  having  been  removed,  should  indicate  the 
possibility  or  probability  that  the  tumor  was  caused  by  the  missing 
dental  organ.  The  importance  of  this  fact  should  not  be  overlooked 
in  the  diagnosis,  for  by  its  careful  observance  many  otherwise  obscure 
cases  may  be  correctly  diagnosed,  and  the  disease  cured  by  a  simple 
operation. 

Aberrations  in  Development  and  Position. — Aberrations  in  the 
form  and  position  of  the  teeth  are  of  interest,  from  the  surgical  stand- 
point, when  by  reason  of  their  non-eruption  they  are  productive  of 
tumors  of  the  maxillary  bones.  A  few  facts  and  suggestions  upon 
some  of  the  causes  of  the  irregularities  in  the  position  of  the  teeth  may 
not,  however,  be  out  of  place  in  this  connection. 

Irregularities  of  the  teeth  are  very  common  among  civilized  na- 
tions, much  more  so,  seemingly,  than  existed  a  few  generations  ago, 
or  than  now  exist  among  the  aborigines,  and  nations  which  by  their 
customs  or  isolated  position  geographically  prevent  immigration  or 
the  intermingling  of  the  blood  of  other  nations  with  their  own. 

In  those  races  and  nations  of  the  highest  civilization,  as  well  as 
those  which  have  received  the  greatest  and  most  varied  admixture  of 
foreign  blood — and  in  the  present  day  these  conditions  may  be  consid- 
ered almost  the  equivalent  of  each  other — irregularities  of  the  teeth 
are  most  frequently  met  with.  The  Anglo-Saxon  race,  and  particu- 
larly the  American  branch  of  it,  is  a  well-known  illustration  of  this 
fact,  as  is  generally  recognized  by  the  most  eminent  dental  pathologists 
and  by  specialists  in  the  department  of  orthodontia. 

The  effect  of  the  intermarriage  of  distinct  races  and  nations  op- 
erates at  first  to  lower  the  vitality  and  physical  endurance,  to  break  up 
the  racial  types  in  the  conformation  of  the  bones  of  the  face,  and  the 
harmonious  relationship  which  naturally  exists  between  the  size  of 
the  jaws  and  the  teeth.     Children  often  inherit  the  physical  peculiari- 


ODONTOMATA.  689 

ties  of  one  parent  and  the  mental  capabilities  of  the  other,  while  in  a 
general  way  it  may  be  stated  that  the  boys  favor  the  mother  and  the 
girls  the  father. 

A  child  may  also  resemble  one  parent  in  the  size  of  the  bony 
framework  and  the  other  in  the  dermal  skeleton,  as  is  frequently  evi- 
denced by  the  size  of  the  body  on  the  one  hand,  and  upon  the  other 
in  the  color  of  the  hair  and  eyes,  the  complexion,  the  size  and  charac- 
teristics of  the  teeth.  Among  animals  the  sire  most  frequently  deter- 
mines the  size  and  general  conformation  of  the  body,  but  the  color 
seems  to  follow  no  definite  rule.  Sometimes,  when  the  colors  of  the 
parents  are  not  the  same,  both  colors  are  reproduced  in  the  offspring, 
particularly  in  horses,  cattle,  and  dogs,  while  in  other  instances  the 
color  of  the  paternal  or  maternal  ancestor  alone  may  be  transmitted. 

These  conditions  may  be  accounted  for  by  the  laws  of  hereditary 
transmission,  operating  through  the  differences  in  the  embryonic 
origin  and  the  morphological  peculiarities  of  the  various  tissues.  The 
skin  and  its  appendages  are  developed  from  the  external  layer  of  the 
germinal  disk  of  Pander,  the  epihlast;  the  teeth,  mucous  membrane,  and 
its  appendages  from  the  internal  layer,  the  hypoblast;  while  the  bones, 
muscles,  connective  tissue,  vital  organs, — in  fact,  the  great  bulk  of  the 
body, — are  developed  from  the  middle  layer,  the  mesoblast.  The  parent 
possessing  the  greatest  vitality  at  the  time  of  conception  usually  exerts 
a  dominating  influence  over  the  development  of  the  embryo,  as  well 
as  the  vital  and  physical  peculiarities  of  the  offspring.  The  same 
proposition  holds  true  in  relation  to  the  mental  endowment,  while  the 
color  of  the  hair,  eyes,  complexion,  and  the  character  of  the  teeth  are 
usually  transmitted  by  the  parent  of  lowest  vital  powers. 

On  the  other  hand,  it  is  frequently  noticed  that  the  male  ofifspring 
seem  to  possess  an  inherent  tendency  to  reproduce  the  physical  and 
mental  peculiarities  of  the  mother,  while  the  female  children  inherit 
the  same  tendency  in  relation  to  the  father.  This  tendency  is  often 
demonstrated  in  the  peculiarities  in  the  form,  position,  and  suppression 
of  the  teeth.  A  somewhat  remarkable  illustration  of  an  inherited 
suppression  of  the  superior  first  bicuspids  came  under  the  notice  of 
the  writer  in  which  the  best  of  evidence  was  presented  that  this  pecu- 
liarity had  existed  in  one  family  for  four  generations. 

The  deformity  was  first  noticed  in  a  young  lady  nineteen  years 
of  age,  the  eldest  of  four  children, — two  girls  and  two  boys.  Neither 
of  the  brothers  nor  the  younger  sister  had  the  deformity.  The  father 
of  these  children  had  never  erupted  these  teeth,  neither  had  his  mother 
nor  her  father.  The  father  of  the  young  lady  had  one  sister,  but  no 
brothers.  The  sister  had  a  complete  set  of  teeth.  The  father's  mother 
was  the  only  member  of  her  family  who  had  the  deformity,  and  al- 
though it  was  commonly  known  in  the  family  that  her  own  father  (the 

45 


690  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

great-grandfather  of  the  young  lady)  had  never  erupted  these  teeth, 
■she  did  not  know  whether  any  of  her  father's  brothers  or  sisters  had 
been  so  afBicted. 

The  various  races  of  mankind  are  distinguished  from  one  another 
principally  by  the  color  of  the  skin,  the  character  of  the  hair,  and  the 
conformation  of  the  features  (this  includes  the  conformation  of  the 
eyes,  nose,  lips,  and  jaws). 

Nations  are  also,  in  a  modified  sense,  recognized  in  the  same  way. 
The  features,  for  instance,  of  the  typical  Irish,  German,  or  English 
peasant  are  so  marked  as  rarely  to  be  mistaken  one  for  the  other. 
The  conformation  of  the  maxillary  arches  is  also  indicative,  in  a  gen- 
eral way,  of  civilization  and  culture  of  races  and  nations.  The  more 
nearly  the  conformation  of  the  typical  maxillary  arch  of  a  race  or  a 
nation  approaches  the  outline  of  the  half  of  an  ellipse  cut  through  its 
short  diameter,  the  higher  the  civilization. 

The  American  nation  is  made  up  principally  of  the  three  nations 
just  mentioned.  The  conformation  of  the  jaws  and  the  characteristics 
of  the  teeth  in  each  are  so  different  as  to  be  readily  distinguished. 
The  intermarriage  of  these  peoples  has  destroyed  the  characteristic 
national  types  of  features,  the  conformation  of  the  jaws,  and  the  regu- 
larity of  the  teeth,  but  eventually  there  will  be  evolved  from  this  mix- 
ture of  nations,  as  in  the  composite  photograph,  a  new  type  of  features 
which  will  be  distinctively  American.  When  this  time  comes  there 
will  be  more  perfect  harmony  between  the  size  of  the  maxillary  arches 
and  the  teeth  than  now  exists,  with  the  result  that  irregularities  in  their 
position  will  be  less  frequent. 

In  children  born  of  parents  with  wide  racial  differences  in  the  size 
of  the  osseous  skeleton,  the  form  of  the  maxillary  bones,  and  the  char- 
acteristics of  the  teeth,  there  is  a  greater  liability  to  irregularities  in 
the  position  of  the  teeth  than  when  those  differences  are  not  so  strongly 
marked.  As  a  result  of  this  liability,  teeth  which  are  out  of  all  har- 
mony to  the  size  of  the  jaws  are  not  uncommon  sights  to  the  observing 
surgeon  and  dentist.  This  lack  of  harmony  may  be  a  combination  of 
small  teeth  in  a  large  jaw,  or  large  teeth  in  a  small  jaw.  In  the  former 
the  teeth  will  stand  widely  apart ;  in  the  latter  they  will  be  crowded  out 
of  position.  Both  are  deformities,  but  the  latter  only  is  amenable  to 
correction  by  the  methods  of  treatment  adopted  by  the  orthodontist. 

Other  important  factors  in  the  causation  of  irregularities  in  the 
position  of  the  teeth  are,  arrested  development  in  one  or  both  jaws, 
but  most  often  observed  in  the  superior  maxilla,  and  the  hereditary 
tendency  in  certain  families  to  malformations  of  the  maxillary  bones. 
The  etiology  of  the  irregularities  of  the  teeth  is  a  topic  of  considerable 
magnitude,  but  it  has  little  bearing  upon  the  subject  of  the  forma- 
tion of  tumors  of  the  jaws,  except  in  a  general  way,  for  it  is  only  when 


ODONTOMATA.  69I 

these  irregularities  in  position  and  development  are  such  as  to  make 
it  impossible  for  certain  teeth  to  erupt  that  they  become  interesting 
from  a  pathologic  and  a  surgical  standpoint. 

Malpositions  of  the  unerupted  teeth  which  are  contained  within 
the  alveolar  processes  and  remote  portions  of  the  maxillary  bones  are 
not  always  productive  of  the  formation  of  tumors.  An  examination 
of  the  skulls  in  the  dissecting-rooms,  and  of  those  found  in  the 
museums,  abundantly  proves  this  statement,  as  such  teeth  have  re- 
mained imbedded  in  the  jaws  for  a  lifetime  without  giving  any  evi- 
dence of  their  abnormal  position. 

The  forms  of  malposition  of  the  teeth  which  are  most  common  in 
the  alveolar  processes  are  those  in  which  the  teeth  lie  horizontally  in 
the  jaws,  or  take  an  obliquely  upward  or  downward  direction,  or  are 
inverted. 

The  horizontal  and  oblique  malpositions  are  usually  associated 
with  the  third  molars  and  the  cuspid  teeth,  and  the  writer,  judging 
from  his  own  experience,  is  of  the  opinion  that  the  inferior  third  molars 
and  the  superior  cuspids  are  more  frequently  retained  in  the  jaws  from 
horizontal  malpositions  than  any  of  the  other  teeth,  or  from  any  other 
cause. 

The  following  cases  are  of  interest  as  illustrating  these  points: 

Tumor  of  the  left  superior  maxilla  in  a  woman  fifty-two  years  of 
age.  Six  months  previously  all  of  the  teeth  had  been  extracted.  The 
tumor  had  been  growing  for  three  months,  and  was  situated  upon  the 
external  surface  and  at  the  base  of  the  alveolar  process,  extending  from 
the  canine  prominence  backward  for  more  than  an  inch.  Operation 
by  drilling  into  the  tumor  revealed  a  tooth,  which  was  removed  with 
some  difficulty,  and  proved  to  be  a  v/ell-developed  cuspid,  one  inch  in 
length.  Its  direction  in  the  jaw  was  nearly  horizontal,  having  an 
oblique  inclination  downward  and  forward.  After  the  removal  of  the 
tooth  the  tumor  rapidly  disappeared. 

Another  case  in  a  woman  of  forty-two  years;  the  tumor  upon  the 
right  side  of  the  vault  of  the  mouth.  Teeth  were  all  lost,  and  she  had 
worn  an  artificial  set  of  teeth  for  three  years;  for  the  last  year  could 
not  wear  the  plate  on  account  of  the  growth  of  the  tumor.  The  patient 
was  sure  that  the  right  superior  cuspid  had  never  erupted.  The  de- 
ciduous cuspid  remained  until  the  other  teeth  were  extracted.  This 
made  the  diagnosis  of  impacted  tooth  quite  plain.  The  tumor  extended 
nearly  the  entire  length  of  the  palate  process  of  the  jaw,  and  from  the 
alveolar  process  to  the  median  line.  A  thick  plate  of  bone  had  to  be 
cut  away  in  both  cases  before  the  tooth  was  reached.  This  also  proved 
to  be  a  well-developed  cuspid  tooth.  The  enlargement'  of  the  jaw 
rapidly  disappeared  after  the  operation,  and  did  not  recur. 

A  third  case  in  a  woman  forty-five  years  of  age;  tumors  or  swell- 


692  SURGERY    OF   THE    FACE,    MOUTH,    AND   JAWS. 

ings  upon  both  sides  of  the  superior  maxilla.  The  teeth  had  all  been 
extracted  from  this  jaw  fifteen  months  before,  and  for  twelve  months 
an  artificial  denture  had  been  worn.  During  the  last  half  of  that  time 
the  denture  had  not  fitted  well,  on  account  of  tumors  or  swellings 
located  upon  the  right  and  left  sides  of  the  maxilla  in  the  alveolar 
ridge,  and  extending  from  about  half  an  inch  from  the  median  line 
back  to  the  region  of  the  first  molar.  The  enlargement  of  the  maxilla 
seemed  to  be  confined  to  the  alveolar  ridge.  Later  the  crowns  of  two 
cuspid  teeth  made  their  appearance  at  the  anterior  part  of  the.  tumors. 
The  direction  of  the  crowns  showed  the  teeth  to  be  lying  in  a  hori- 
zontal position  in  the  jaw.  They  were  extracted  with  little  difficulty. 
These  teeth  are  well-formed  cuspids,  evidently  not  supernumerary 
teeth,  as  the  patient  gives  a  clear  history  of  retained  deciduous  cuspids 
which  were  not  lost  until  a  short  time  before  the  jaw  was  cleared  of 
teeth  for  the  purpose  of  inserting  the  artificial  denture. 

The  third  molars,  in  the  experience  of  the  writer,  are  rarely  pro- 
ductive of  solid  tumors  of  the  jaws.  Malpositions  of  these  teeth, 
producing  impaction,  are  much  more  likely  to  cause  acute  symptoms 
of  inflammation,  the  formation  of  cysts,  and  neuralgic  affections,  both 
local  and  reflex,  than  to  result  in  the  development  of  osseous  tumors. 
Occasionally  there  will  be,  as  a  result  of  the  irritation  produced  by  the 
impacted  tooth,  more  or  less  hyperplasia  of  the  overlying  bone-ti'^^ue. 
but  rarely  a  condition  which  could  be  termed  a  distinct  solid  tumor. 

Inversion  is  usually  confined  to  the  third  molars,  but  occasiorallv 
other  teeth  may  have  this  malposition.  The  deciduous  teeth  are  larelv 
the  subjects  of  retention  in  the  jaws  by  reason  of  malpositions,  while 
inversion  of  these  teeth  is  still  more  rare. 

One  such  case  occurring  in  a  first  superior  deciduous  molar  which 
was  inverted  has  already  been  referred  to  in  another  chapter  of  this 
work  (page  509). 

The  most  common  malpositions  occurring  in  other  portions  of 
the  jaws — outside  of  the  alveolar  processes — are  those  in  which  the 
tooth  lies  in  the  palate  process  of  the  superior  maxilla,  or  projects  into 
the  palate  bone.  Forget  mentions  a  case  of  this  character  in  a  woman. 
The  tumor  was  located  upon  the  left  side,  and  extended  from  the  region 
of  the  cuspid  tooth  to  the  soft  palate,  and  reached  beyond  the  median 
line.  Blandin,  in  operating  for  its  removal,  discovered  its  cause  to  be 
two  dwarfed  and  abnormally-placed  molar  teeth  which  had  taken  a 
direction  toward  the  median  line  and  had  penetrated  the  palatal  wall 
of  the  alveolar  process.  Tomes  records  a  similar  case  of  tumor  of  the 
palate  caused  from  a  misplaced  molar  tooth. 

Exceptional  malpositions  of  the  teeth  of  the  inferior  maxilla  are 
the  projection  of  the  third  molar  into  the  sigmoid  notch,  or  its  location 
in  other  portions  of  the  ramus.     These  forms  of  malposition,  however, 


ODONTOMATA.  693 

would  be  more  likely  to  induce  acute  inflammatory  symptoms  with 
suppuration,  or  cystic  tumor,  than  the  formation  of  a  solid  growth. 

Rare  malpositions  of  the  third  molar  teeth  of  the  superior  maxilla, 
like  the  penetration  of  the  cheek  or  the  floor  of  the  antrum  of  High- 
more,  are  occasionally  recorded.  Tomes  describes  a  case  in  which  the 
superior  third  molar  projected  through  the  cheek,  and  the  writer  has 
referred  to  a  case  in  another  part  of  this  work  in  which  the  superior 
third  molar  penetrated  the  antrum  of  Highmore,  and  was  eventually 
expelled  from  the  nose  through  the  posterior  nares. 

Diagnosis  and  Symptoms. — The  diagnosis,  as  already  suggested, 
is  sometimes  exceedingly  difficult  to  reach.  The  age  of  the  patient 
should  be  first  ascertained,  and  the  progress  of  second  dentition  noted, 
in  those  oassing  through  this  period,  to  see  if  the  teeth  proper  to  a 
certain  age  have  made  their  appearance;  or  if  the  individual  is  an 
adult,  and  the  tooth  is  missing  in  the  location  of  the  tumor  which 
cannot  be  accounted  for,  this  should  indicate  with  considerable  cer- 
tainty that  the  tumor  is  caused  by  a  malposed  unerupted  tooth. 

Supernumerary  teeth  which  are  impacted  in  the  jaws  may  also  be 
the  cause  of  tumors  of  this  character.  It  is  therefore  possible  that 
such  a  tumor  may  occur  in  a  jaw  in  which  the  full  complement  of  teeth 
are  in  position,  by  the  presence  of  a  supernumerary  tooth  imbedded 
within  the  alveolar  process  or  other  portions  of  the  maxillary  bone. 

The  symptoms  are  simply  a  slow,  painless,  progressive  enlarge- 
ment of  a  certain  portion  of  the  maxillary  bone,  which  may  be^  so 
small  or  so  located  as  not  to  cause  any  inconvenience  or  deformity; 
while,  upon  the  other  hand,  its  position  and  size  may  be  such  as  to 
cause  great  inconvenience  or  deformity,  or  both. 

Prognosis.— The  prognosis  in  this  form  of  tumor  is  always  good. 
The  removal  of  the  cause  is  all  that  is  necessary  to  insure  a  complete 

cure. 

Treatment.— The  treatment  in  all  cases  of  solid  growths  of  the 
jaws  is  to  first  make  an  exploratory  puncture  with  needle,  trocar,  or 
drill.  If  the  tumor  contains  a  tooth,  the  exploring  instrument  will  at 
once  indicate  this  by  the  greater  density  of  this  portion  of  the  tumor  as 
compared  with  the  overlying  tissue  and  the  peculiar  sensation  trans- 
mitted through  the  probe  by  contact  with  the  tooth  itself. 

This  fact  being  established,  it  only  remains  for  the  surgeon  to  cut 
do\vn  upon  the  tooth  with  gouge  or  bur  and  remove  it,  after  which  the 
enlargement  of  the  bone  will  gradually  disappear,  and  eventually  re- 
sume its  normal  size. 


CHAPTER    LXVI. 


RETENTION  CYSTS. 

Definition. — "A  retention  cyst  is  a  swelling  caused  by  the  accumu- 
lation of  a  physiologic  secretion  or  excretion  in  a  gland  or  its  duct,  by 
obstruction  of  its  natural  outlet." 

The  retention  cysts  which  are  located  in  the  region  of  the  face  and 
mouth  are  associated  either  with  the  glandular  structures  of  the  skin, 


Vertical  Section  through  the  Healthy  Skin. 
a,  Epidermis  ;  b,  Rete  Malpighii ;  c,  Papillary  layer  ;  d,  Derma  ;  e,  Adipose  tissue  ;  /,  £-,  k,  Sweat- 
gland  and  duct ;  z,  Hair;  k,  Hair-follicle  and  papilla;  /,  Sebaceous  gland. 


the  mucous  membrane,  or  the  salivary  gland 
grouped  as  follows : 

Sebaceous  Cysts, 

Sudoriparous  Cysts, 

Muciparous  Cysts, 

Ranula, 
694 


These  cysts  may  be 


Skin. 

Mucous  Membrane. 
Salivary  Glands. 


retention  cysts.  695 

Cysts  of  the  Skin. 

The  glandular  structures  of  the  skin  are  the  sebaceous  or  oil 

glands,  and  the  sudoriparous  or  sweat  glands.     The  sebaceous  glands 

belong'  to  that  class  of  glandular  structures  known  as  racemose,  while 

the  su'doriparous  glands  belong  to  the  coil  form  of  glandular  structures 

(Fig.  388). 

'under  normal  conditions  the  epithelial  structures  of  the  sebaceous 
glands  secrete  an  oily  liquid  known  2.s  sebum,  which  becomes  con- 
densed in  the  gland  or  its  duct,  into  a  yellowish  semi-fluid,  greasy 
material,  of  peculiar  odor,  and  containing  disintegrated  epithelial  cells. 
The  accumulation  and  retention  of  sebum  in  the  glands  or  ducts,  as  a 
result  of  obstruction  of  the  outlet,  is  productive  of  various  disorders  of 
the  skin.  Among  them  may  be  mentioned  Comedo,  Milium,  and 
Wens,  which  are  forms  of  cysts. 

Comedo,  vulgarly  known  as  "black  heads,"  is  a  disease  in  which 
the  condensed  secretion  of  the  sebaceous  glands  is  retained  in  the  ex- 
cretory ducts,  and  becomes  visible  upon  the  surface  of  the  skin  in  yel- 
lowish-white or  brownish-black  points  (Hyde).  This  material  is  com- 
posed of  sebum  and  horny  epidermal  cells,  which  occasionally  contain 
minute  hairs  and  the  parasite  Demodex  folliculorum  (Ziegler).  Pres- 
sure, if  applied,  will  express  the  material  in  the  form  of  a  small  plug, 
which  is  popularly  called  the  "worm." 

Comedones  are  most  frequently  located  upon  the  face;  the  nose,, 
forehead,  cheeks,  and  chin  being  the  most  favored  sites  of  the  disease. 
It  is  most  frequently  observed  at  the  age  of  puberty,  and  both  sexes  are 
equally  liable  to  the  affection.  The  disease,  however,  is  not  confined 
to  this  period  of  life,  for  it  is  occasionally  seen  at  all  ages. 

Causes.— The  etiology  of  the  disease  is  somewhat  obscure.  It  is 
sometimes  associated  with  an  improper  care  of  the  skin,  but  neglect  is 
not  always  followed  by  the  disease,  for  certain  of  the  trades,  like  coal 
heavers,  chimney  sweeps,  machinists,  masons,  etc.,  whose  faces  are 
constantly  begrimed,  are  very  rarely  affected  with  the  disease.  On  the 
other  hand,  it  is  frequently  seen  upon  the  faces  of  young  men  and 
women  of  the  better  social  classes,  whose  habits  of  cleanliness  and 
forms  of  recreation  are  of  the  most  healthful  character  (Hyde).  The 
disease  is  generally  considered  as  one  peculiarly  liable  to  appear  durmg: 
the  age  of  puberty,  and  in  some  way  associated  with  the  development 
of  the^sexual  functions.  Dyspepsia,  constipation,  scrofulosis,  chlorosis, 
and  menstrual  irregularities,  are  unquestionably  associated  m  the 
causation  of  the  disease. 

Treatment— The  treatment  should  be  first  directed  to  the  correc- 
tion of  the  constitutional  conditions  just  mentioned,  by  the  use  of  in- 
ternal medication,  such  as  the  bitter  tonics,  iron,  cod-liver  oil,  cathar- 
tics, and  malt  preparations,  as  indicated  by  the  special  needs  of  the 


696  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

patient.  Ont-door  exercise  and  hygienic  rules  in  general  are  to  be  car- 
ried out.  The  local  treatment  consists  of  frequent  bathing  with  hot 
water,  followed  by  thorough  drying,  and  anointing  the  face  at  night 
with  one  of  the  following  preparations: 

Ointment. 

5— Sulf.  precip.,  3j ; 
Vaselin,  oj.     M. 

Or  the  following  lotion  may  be  applied: 

Lotion. 

ij — Sulf.  precip., 
Alcohol, 

Tinct.  lavend.  comp., 
Glycerol, 
Aquse  camph.,  aa  oj.     M. 

(Hyde.) 

Unna  recommends  the  following  paste  for  the  removal  of  the 
comedones,  to  be  applied  morning  and  night: 

5 — Acetic  acid,  5ij ; 
Glycerol,  oiij ; 
Kaolin,  oiv. 

The  plugs  may  be  dislodged  by  pressure  with  the  finger-nail,  a 
spatula,  or  with  a  watch-key  applied  over  the  spots. 

Milium  or  Grutum  appear  as  minute,  roundish,  white  or  yellowish 
elevations  of  the  skin  (Ziegler).  They  are  millet-seed  to  pin-head 
sized,  globular  masses,  rarely  attaining  the  size  of  a  cofifee  bean,  and 
having  the  appearance  of  kernels  of  rice,  lying  beneath  the  translucent 
layer  of  the  skin  (Hyde).  They  are  due  to  the  accumulation  of  sebum 
and  worn-out  epithelial  cells,  in  the  sebaceous  glands  whose  ducts  have 
been  obliterated.  When  the  nodules  are  opened,  the  contents  are 
often  found  to  be  concreted  into  a  firm  and  sometimes  calcareous  mass. 
Occasionally  they  project  from  the  surface  of  the  skin  in  such  a  man- 
ner as  to  resemble  small  vesicles  (Hyde),  containing  a  creamy-white 
substance.  Locations  in  which  they  are  most  commonly  seen  are  the 
eyelids,  the  cheeks,  and  the  temples,  though  they  are  sometimes  seen  in 
other  portions  of  the  body.  They  are  often  of  congenital  origin,  and 
are  frequently  seen  upon  the  eyelids  and  temples  of  new-born  infants. 
The  disease  is  sometimes  developed  in  middle  life.  Its  progress  at 
such  times  is  slow,  and  it  may  persist  for  an  indefinite  period,  some- 
times for  several  years. 

Causes. — The  etiology  of  milium,  like  that  of  comedo,  is  obscure. 
The  disease  is  sometimes  produced  by  accidental  or  surgical  injury  to 
the  sebaceous  gland,  whereby  one  or  more  of  the  acini  are  cut  off  from 
the  main  body  of  the  gland,  and  its  duct  is  obliterated.     The  contrac- 


RETENTION    CYSTS.  697 

tion  of  cicatricial  bands  may  also  obliterate  the  duct,  and  cause  a 
similar  result.  In  general  terms  it  may  be  stated  that  the  disease  is 
caused  by  any  condition  which  prevents  the  normal  transformation  of 
the  lining  epithelial  cells  of  the  glands  into  sebum,  and  the  excretion  of 
this  substance  upon  the  surface  of  the  skin. 

Treatment. — Milium  is  a  disease  which  rarely  requires  treatment. 
Milia  are  relatively  few  in  number,  cause  no  pain,  no  deformity,  or 
other  unpleasant  symptom.  When  treatment  is  required,  each  eleva- 
tion may  be  opened,  the  cheesy  matter  turned  out,  and  the  interior  of 
the  cyst  touched  with  the  tincture  of  iodin  or  with  a  25  per  cent,  solu- 
tion of  the  nitrate  of  silver.  Hyde  recommends  a  50  per  cent,  solution 
of  chromic  acid  to  destroy  the  gland  and  prevent  a  recurrence.  Elec- 
trolysis is  also  used  for  the  same  purpose. 

Sebaceous  Cysts  or  Wens. — The  development  of  sebaceous  cysts 
does  not  materially  differ  from  that  of  milia.  They  originate  from 
occlusion  of  the  natural  outlet  of  the  gland,  which  soon  becomes  dis- 
tended by  the  accumulation  of  a  more  or  less  fluid  secretion,  resulting 
in  the  formation  of  a  cyst.  The  gland,  its  duct,  and  the  hair-follicle, 
are  all  involved  in  the  cyst,  which  may  be  as  large  as  a  pea,  or  attain 
the  size  of  a  large  walnut,  or  exceptionally  even  greater  dimensions. 
They  are  usually  of  slow  growth,  and  are  devoid  of  painful  sensations. 
They  appear  as  single  or  multiple  tumors,  most  frequently  situated 
upon  the  scalp,  and  they  are  sometimes  found  upon  the  back  of  the 
neck,  and  upon  the  face,  but  less  often  upon  the  trunk  and  the  limbs. 
Their  situation  may  be  upon,  within,  or  beneath  the  skin.  They  are 
usually  adherent  to  the  deeper  or  subcutaneous  tissue,  and  are  covered 
by  integument,  which  is  usually  devoid  of  hair.  The  overlying  skin 
may  be  normal  in  color,  or  abnormally  pale  from  pressure,  or  reddened, 
shiny,  and  greasy  in  appearance,  especially  upon  the  bald  scalp  of  cer- 
tain fleshy  men  of  middle  life  (Hyde).  The  contents  of  a  sebaceous 
cyst  may  be  soft  and  pulpy,  or  firm  and  friable.  Occasionally  they  are 
fluid  and  creamy,  or  fluid  and  purulent.  They  consist  of  fatty  detritus, 
sebum,  epidermal  cells,  undeveloped  hair,  and  sometimes  crystals  of 
cholesterin  (Ziegler),  inclosed  in  a  capsule  composed  of  layers  of  epi- 
thelial cells  and  fibrous  tissue. 

Papillary  growths,  covered  with  epidermoid  cells,  sometimes  arise 
from  the  inner  surface  of  the  walls  of  a  sebaceous  cyst,  and  may  in- 
crease to  such  an  extent  as  to  completely  fill  the  cyst  (Ziegler).  The 
internal  layer  of  cells  may  become  dry  and  horny  (Chiari).  In  time 
it  may  become  calcified  (Forster). 

Causes. — ^The  causes  which  produce  sebaceous  cysts  are  injuries 
of  a  traumatic  or  surgical  nature,  and  inflammatory  conditions  of  the 
skin,  which  bring  about  a  permanent  occlusion  or  obstruction  of  the 
secretory  duct. 


698  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

Prognosis. — Sebaceous  cysts,  if  injured,  are  liable  to  inflame  and 
ulcerate.  Their  removal,  particularly  when  located  in  the  scalp,  has 
been  followed  by  erysipelas.  With  ordinary  care  as  to  surgical  cleanli- 
ness such  a  result  would  hardly  follow.  In  the  aged  these  cysts  some- 
times take  on  a  carcinomatous  degeneration. 

Treatment. — Excision  or  enucleation  should  be  performed,  either 
by  cutting  through  the  cysts  and  tearing  out  each  half  of  the  cyst-walls 
with  a  pair  of  forceps,  or  by  cutting  through  the  overlying  skin  and 
carefully  dissecting  out  or  enucleating  the  cyst. 

Sudoriparous  Cysts. — Cysts  of  the  sweat-glands  are  of  very  rare 
occurrence,  and  little  is  known  about  them.  They  have  their  origin  in 
the  obstruction  or  occlusion  of  the  duct  of  the  gland,  and  instead  of  the 
gland  becoming  inflamed  and  suppurating,  the  fluid  collects  and  dis- 
tends the  duct.  (Tilbury  Fox.)  The  occasional  appearance  of  mois- 
ture upon  the  surface  of  the  swelling,  the  result  of  leakage  in  a  partially 
obstructed  duct,  has  been  considered  to  be  a  pathognomonic  symptom. 
This  form  of  cyst  is  sometimes  seen  upon  the  face,  as  the  result  of  the 
cicatrices  of  acne,  which  have  obliterated  the  ducts  of  the  sweat-glands. 
In  strumous  subjects  it  is  sometimes  quite  difficult  to  cure. 

Treatment.- — The  treatment  consists  of  puncturing  the  cysts  and 
allowing  the  contents  to  escape,  followed  by  repeated  application  of 
flexible  collodium,  or  excision  of  the  glands  may  be  practiced.  The 
latter  method  is  most  reliable. 

Cysts  of  the  Mucous  Membrane. 

The  mucous  membrane  and  the  skin  are,  from  the  anatomic  stand- 
point, closely  related  to  each  other,  the  difference  being  that  in  the  skin 
the  epithelium  is  composed  of  squamous  cells  arranged  in  stratified 
layers,  while  in  the  mucous  membrane  the  epithelium,  with  few  excep- 
tions, is  composed  of  columnar  cells  arranged  in  a  single  layer. 

The  mucous  membrane  is  also  more  highly  endowed  with  glandu- 
lar structures.  The  mucous  glands  have  their  counterpart  in  the 
sebaceous  glands  of  the  skin,  and  the  retention  of  their  secretions  re- 
sults in  the  formation  of  cysts,  which  have  their  representatives  in  the 
retention  cysts  of  the  skin  (Fig.  389). 

The  mucous  glands  of  the  mouth  (the  labial,  buccal,  lingual,  and 
palatal)  are  for  the  most  part  tubular  and  racemose  glands.  The  nor- 
mal secretion  of  these  glands  is  a  grayish,  viscid  fluid,  containing  a 
number  of  leucocytes  and  desquamated  epithelial  cells.  The  mucus 
secreted  by  these  glands  is  of  great  service  to  the  membrane  in  both 
normal  and  abnormal  conditions,  as  it  forms  a  protective  covering,  and 
assists  in  preventing  injury  to  the  membrane  from  the  effects  of  harm- 
ful influences  or  substances  which  might  come  in  contact  with  it. 


RETENTION    CYSTS. 


699 


Muciparous  Cysts. — Muciparous  cysts  of  the  oral  mucous  mem- 
brane are  quite  common,  and  they  are  found  located  upon  the  lips, 
cheeks,  palate,  and  tongue.  They  are  small  in  size,  varying  from  pin- 
head  points  to  that  of  a  filbert  nut  or  almond.  The  walls  of  the  cysts 
are  exceedingly  delicate ;  the  mucous  membrane  covering  them  is  very 
thin,  being  sometimes  almost  transparent,  and  easily  ruptured.  They 
contain  a  viscid  fluid,  but  if  the  cyst  is  one  of  long  standing,  the  fluid 
may  undergo  change  and  become  serous  in  character.  These  cysts 
often  rupture  spontaneously,  and  leave  a  deep  circular  ulcer,  which  is 
sometimes  slow  to  heal,  if  left  to  itself. 


Fig..  389. 


Vertical  Section  through  the  Mucous  Membrane  of  Lip  of  Adult  Man.    X  30. 


VERTICAL    C51iCliUi^     ini^wi_/vj.*     *  ..^ 

I  Papilla-  2  Excretory  duct,  the  lumen  is  cut  open  at  one  point  only;  3,  Accessory  gland; 
4,  Branch  of  the  excretory  duct  in  transverse  section;  5,  Gland  follicles  grouped  into  lobules 
by  connective  tissue  ;  6,  A  gland  tubule  in  transverse  section. 

The  lips  are  the  most  common  seat  of  these  cysts,  the  lower  more 
than  the  upper.  The  frequency  with  which  they  are  found  in  the  other 
locations  may  be  indicated  in  the  following  order:  the  cheeks,  the 
tongue,  and  the  palate.  These  cysts  are  usually  single,  and  several 
may  appear  at  the  same  time  in  the  same  neighborhood. 

Multiple  mucous  cysts  of  the  lips  sometimes  occur,  and  cause  such 
extensive  thickening  of  the  lips  as  to  give  them  the  appearance  of  be- 
ing double.  Excision  of  the  cysts  restores  the  lips  to  their  normal  size 
and  form.  In  origin  and  appearance  the  mucous  cysts  of  the  cheeks 
differ  in  no  way  from  those  found  upon  the  lips. 


700  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS. 

The  muciparous  cysts  of  the  soft  palate,  and  especially  of  that 
portion  lying  in  the  vicinity  of  the  tonsils,  are  of  frequent  occurrence. 
They  are  recognized  by  their  form,  which  is  usually  globular  or  ovoid, 
and  by  the  sense  of  fluctuation  (Cohen)  when  palpation  is  employed. 
They  are  usually  small  in  size,  rarely  exceeding  the  dimensions  of  a 
buckshot,  though  they  occasionally  reach  the  size  of  a  pigeon's  egg. 

The  tongue  is  rarely  the  seat  of  retention  cysts,  but  when  they  do 
occur  they  are  located  upon  the  dorsum  or  the  borders,  and  more  fre- 
quently in  the  posterior  portion  where  the  mucous  glands  are  most 
numerous.  In  size  they  rarely  exceed  that  of  an  almond.  In  shape 
they  are  globular  or  ovoid;  the  mucous  membrane  covering  them  is 
smooth  (Butlin),  and  their  outlines  are  well  defined.  Fluctuation  can 
be  detected  in  the  larger  cysts,  and  when  near  the  surface  the  mem- 
brane covering  them  is  translucent.  Mucous  cysts  of  the  tongue  are 
observed  most  frequently  in  adults,  though  they  may  occur  at  any  age. 

Causes. — Muciparous  cysts  are  caused  by  obstruction  or  occlusion 
of  the  ducts;  or  are  due  to  an  over-secretion  of  fluid  by  the  glands.  In 
either  case  the  result  is  distention  of  the  gland  and  its  duct  by  the  ac- 
cumulation of  the  secretion,  and,  in  time,  the  development  of  a  definite 
swelling  or  enlargement  of  the  part.  Occlusion  of  the  duct,  however, 
is  not  an  absolute  essential  to  the  formation  of  retention  cysts.  Ob- 
struction of  the  duct  by  a  narrowing  of  its  orifice,  or  by  a  stricture 
located  in  any  portion  of  the  duct  which  caused  a  partial  occlusion, 
would  under  these  circumstances  be  effectual  in  producing  a  cyst,  as  it 
would  prevent  the  free  escape  of  the  secreted  fluid. 

Diagnosis  and  Symptoms. — The  diagnosis  of  muciparous  cysts  of 
the  mucous  membrane  of  the  lips  and  the  cheeks  is  generally  a  very 
simple  matter,  as  they  usually  lie  near  the  surface,  and  are  distinguished 
by  their  limited  size,  the  translucency  of  the  overlying  mucous  mem- 
brane, their  slow  development  and  painless  character.  Mucous  cysts 
of  the  palate  and  tongue  are  sometimes  more  difficult  to  diagnose,  es- 
pecially when  they  are  small  and  rather  deep-seated.  The  difficulty 
lies  in  being  able  to  differentiate  them  from  solid  tumors  like  the 
fibroma  and  lipoma,  or  from  a  chronic  abscess.  The  only  means  of 
positive  diagnosis  is  by  an  exploratory  puncture. 

There  are  no  subjective  symptoms,  and  the  cyst  may  not  be  recog- 
nized until  it  has  attained  a  sufficient  size  to  cause  inconvenience,  or 
ruptures  spontaneously  and  is  followed  by  an  ulcer. 

Treatment. — The  treatment  of  mucous  cysts  to  be  curative  requires 
the  excision  of  the  cyst  or  the  destruction  of  its  walls.  Excision  may 
be  employed  in  cysts  of  small  size.  In  those  of  large  size  the  con- 
tents are  evacuated  by  puncture  or  incision,  and  afterward  the  walls 
of  the  cyst  are  destroyed  by  cauterization  with  stick  nitrate  of  silver  or 
chromic  acid,  or  by  the  injection  of  irritating  substances,  like  carbolic 


RETENTION    CYSTS.  _  7^1 

acid  or  the  tincture  of  iodin,  to  excite  inflammation  and  obliteration  of 
the  gland.  When  the  cyst  is  very  large  it  may  be  packed  with  anti- 
septic gauze  to  promote  healing  by  granulation. 

Mucous  Cysts  of  the  Antrum  of  Highmore. — Cysts  of  the  antrum, 
arising  from  the  mucous  follicles  of  its  lining  membrane,  have  been 
found  of  such  dimensions  as  to  fill  the  entire  cavity,  and  to  cause 
disfigurement  by  the  distention  of  its  bony  walls.  (Giraldes.)  Cases 
of  this  character  are  likely  to  be  mistaken  for  mucous  engorgement  of 
the  antrum  resulting  from  hypersecretion  due  to  catarrhal  conditions  of 
the  membrane.  In  fact,  there  seems  to  be  no  way  of  reaching  an  abso- 
lute diagnosis  in  these  cases  except  by  making  a  temporary  resection  of 
the  anterior  wall  of  the  antrum.  Senn  makes  this  operation  "by  de- 
taching from  within  the  mouth,  with  a  small  chisel,  a  quadrangular 
muco-osseous  flap  on  three  sides,  and  fracturing  its  fourth  or  upper 
side;  by  raising  this  flap  the  antrum  is  thoroughly  exposed  and  every 
part  accessible  to  treatment." 

This  is  an  admirable  method  of  gaining  access  to  the  antrum  in  all 
cases  where  it  is  necessary  to  secure  an  ocular  examination  of  this 
cavity  to  settle  a  doubtful  diagnosis.  The  flap  can  be  replaced  and 
stitched  in  position  by  a  few  catgut  sutures.  Union  takes  place  in  a 
few  days  and  the  integrity  of  the  antrum  is  restored,  which  certainly  is 
better  in  these  cases  than  to  leave  a  large  opening  by  the  sacrifice  of 
tissue,  and  which  may  fail  to  close  by  granulation. 

Treatment. — The  treatment,  after  the  antrum  has  been  opened, 
consists  of  thoroughly  removing  the  walls  of  the  cyst  and  curetting 
the  inner  surface  of  the  sinus  at  the  point  of  origin  of  the  cyst.  Drain- 
age should  be  secured  for  a  few  days  at  the  lowest  point  of  the  flap. 
Senn  recommends  the  estabHshment  of  free  drainage  through  the  nose. 

Cysts  of  the  Salivary  Glands. 

Ranula  is  a  term  applied  to  retention  cysts  of  the  ducts  of  the 
submaxillary  and  sublingual  glands  (Wharton's  and  Rivini's  ducts). 

Cysts  of  the  duct  of  the  parotid  glands  (Stenson's  duct)  also  occa- 
sionally occur,  but  in  comparison  wath  the  prevalence  of  cysts  in  the 
ducts  of  the  salivary  glands  of  the  floor  of  the  mouth  they  are  very 
rare.  A  ranula  is  a  collection  of  salivary  fluid  in  the  excretory  duct  of 
the  salivary  gland.  Its  most  common  location  is  in  the  floor  of  the 
mouth,  beneath  the  tongue,  upon  either  side  of  the  median  line.  It 
varies  in  size  from  that  of  a  pea  to  a  pigeon's  egg,  or  it  may  be 
so  large  as  to  crowd  the  tongue  back  into  the  fauces  and  threaten  suf- 
focation. Its  walls  may  be  thick  or  thin,  and  the  swelling  hard  and 
firm,  or  soft  and  fluctuating. 

A  thick-walled  hard  swelling  indicates  a  cyst  of  long  standing  and 


702  SURGERY    OF   THE    FACE,    MOUTH,    AND    JAWS, 

inflammatory  thickening,  with  contents  greatly  changed  from  the  nor- 
mal secretion,  while  a  thin-walled,  soft,  fluctuating  swelling  is  evidence 
of  a  recently-formed  cyst,  with  a  fluid  more  nearly  approximating  a 
normal  secretion.  The  contents  of  the  cyst  will  vary  in  character  ac- 
cording to  its  period  of  existence.  In  cysts  of  recent  formation,  the 
contents  are  a  clear,  watery  fluid,  an  unchanged  secretion  from  a  nor- 
mal gland.  In  cysts  of  longer  standing  the  fluid  may  become  thick 
and  ropy  or  gelatinous.  Ordinarily  the  contents  are  a  yellowish, 
tenacious,  ropy,  albumen-like  substance,  too  thick  to  flow  from  the  cyst 
without  pressure  upon  its  walls  after  an  incision  has  been  made  for  its 
evacuation.  Occasionally  the  cyst  will  rupture  spontaneously  and  the 
tumor  disappear  as  if  by  magic.  One  such  case  the  writer  had  under 
observation  for  over  ten  years,  in  which  this  process  was  repeated 
several  times. 

x\ll  tumors  situated  beneath  the  tongue  are  not  necessarily  ranula. 
Cystic  tumors  of  other  varieties  are  not  infrequently  found  in  the  floor 
of  the  mouth,  such  as  muciparous  cysts  of  the  Blandin-Nuhn  gland,  and 
dermoid  cysts  and  cystic  hygroma. 

Ranula  is  a  common  affection  of  men,  women,  and  children,  but  is 
more  frequently  seen  in  adults  than  in  children.  Congenital  ranula 
has  also  been  described  by  Lannelongue.  Butlin  thinks  that  the  so- 
called  congenital  ranula  is  probably  "congenital  cystic  hygroma,  or  one 
of  the  cysts  belonging  to  such  a  tumor." 

Causes. — The  causes  of  ranula  are  contraction  or  stenosis  of  the 
excretory  duct,  or  cicatricial  obliteration  due  to  traumatic  injuries  or 
inflammatory  processes,  or  to  the  presence  of  foreign  substances  within 
the  duct.  Richet  in  one  case  discovered  the  cause  of  the  obstruction 
to  be  a  fragment  of  a  blade  of  grass.  The  writer  in  one  case  found  a 
barley  beard  lodged  in  the  duct  of  Wharton  as  a  cause  of  the  obstruc- 
tion; in  another  the  bristle  of  a  tooth-brush,  both  causing  inflamma- 
tion and  stenosis,  and  in  a  third  a  small  salivary  calculus  plugged  the 
orifice  of  the  duct.  The  most  common  causes  are  stenosis  and  cicatri- 
cial obliteration  due  to  injuries  and  inflammation. 

Occlusion  or  obliteration  of  the  excretory  duct  are  not  absolutely 
necessary,  according  to  Bernard,  Weber,  Baker,  and  Senn,  for  the  pro- 
duction of  ranula.  All  of  these  observers  have  seen  cases  of  cysts  in 
Wharton's  duct  in  which  the  orifice  was  patulous,  and  a  probe  could  be 
passed  into  the  cyst.  Senn,  by  pressure,  could  evacuate  the  contents 
through  the  orifice  of  the  duct.  Ranula  sometimes  follows  amputation 
of  the  tongue  from  injury  or  implication  of  the  salivary  ducts  in  the 
cicatrix  of  the  wound.  It  often  results  from  superficial  ulcers  of  the 
mucous  membrane  located  in  the  immediate  neighborhood  of  the 
orifices  of  the  ducts. 

Sonnenburg  and  Von  Recklinghausen  believed  these  cysts  were 


RETENTION    CYSTS.  703 

due  to  dilatation  of  the  Blandin-Nuhn  gland,  which  is  situated  in  the 
floor  of  the  mouth  beneath  the  frenum  lingnce.  This  is  a  racemose 
mucous  gland. 

Diagnosis  and  Symptoms. — The  diagnostic  signs  of  ranula  are  a 
progressively-increasing  swelling  located  in  the  floor  of  the  mouth  be- 
neath the  tongue,  upon  either  side,  accompanied  by  a  sense  of  fullness, 
and  of  painless  character.  In  appearance  it  is  a  smooth,  bulging 
tumor  of  bluish  tint  and  sometimes  translucent  aspect.  When  of  large 
size,  the  tongue  is  lifted  up  and  there  is  fullness  in  the  submaxillary 
triangle;  the  swelling  is  not  painful  to  the  touch,  or  only  slightly  so;  it 
mav  be  hard  or  fluctuating,  of  long  or  recent  existence.  When  the 
former,  it  is  hard  and  firm;  when  the  latter,  it  is  soft  and  fluctuating. 
A  positive  diagnosis  may  be  made  by  the  introduction  of  an  exploring 
needle. 

Prognosis. — Recurrence  is  the  rule  unless  a  permanent  orifice  to 
the  duct  can  be  established,  or  a  radical  operation  is  made  for  the  re- 
moval of  the  gland. 

Treatment. — ^The  main  object  in  the  treatment  of  ranula  is  to  se- 
cure the  establishment  of  an  artificial  orifice  of  the  excretory  duct, 
which  shall  answer  the  purpose  of  a  normal  apparatus.  This  can  only 
be  secured  by  a  surgical  procedure. 

Various  methods  of  surgical  treatment  have  been  suggested  and 
practiced  with  this  end  in  view : 

1st.  The  evacuation  of  the  cyst  by  free  incision  of  its  superior 
wall  is  a  common  method;  but  this  affords  only  temporary  relief,  as  it 
is  usually  but  a  short  time  before  the  wound  closes  and  the  fluid  reac- 
cumulates. 

2d.  Excision  of  a  portion  of  the  superior  wall  of  the  cyst  at  its 
anterior  extremity,  followed  by  cauterization  of  the  cyst  walls,  gives 
better  success,  and  yet  even  this  treatment  does  not  in  some  instances 
give  the  desired  result.  This  is  explained  by  the  fact  that  after  the 
contents  of  the  cyst  have  been  evacuated,  the  edges  of  the  wound  fall 
together,  and  they  are  eventually  united,  and  the  object  of  the  opera- 
tion is  defeated. 

3d.  Another  method  is  to  introduce  a  seton  through  the  walls  of 
a  cyst,  and  allow  it  to  remain  until  permanent  openings  are  secured  at 
the  points  of  entrance  and  exit  of  the  seton.  The  operation  consists  of 
threading  a  large,  full-curved  needle  (Fig.  390),  with  heavy  braided 
silk  previously  waxed,  or  with  silver  wire,  and  passing  the  needle 
through  the  walls  of  the  cyst  from  side  to  side,  near  the  anterior  ex- 
tremity, cutting  the  suture  of  proper  length,  and  uniting  the  ends  by 
tying  the  silk  and  twisting  the  wire.  The  seton  should  remain  from 
one  to  two  weeks,  or  until  such  time  as  the  punctures  in  the  cyst  wall 
have  healed  around  the  seton.     After  the  seton  has  been  secured  the 


704  SURGERY    OF    THE    FACE,    MOUTH,    AND    JAWS. 

cyst  should  be  opened  by  an  incision,  and  its  contents  evacuated.     This 
method  gives  good  resuhs. 

4th.  Another  method  of  securing  a  permanent  opening  in  the 
wall  of  the  duct  is  to  make  a  V-shaped  incision  in  the  superior  wall  of 
the  cyst,  turn  back  the  triangular  flap  thus  made,  and  stitch  it  in  its 
new  position.  This  leaves  a  somewhat  large  opening,  which  will  in 
some  cases  remain  patulous  and  give  free  exit  to  the  secreted  fluid. 

5th,  A  more  heroic  method,  based  upon  the  supposition  that  the 
disease  is  due  to  the  dilatation  of  the  acini  of  the  Blandin-Nuhn  gland, 
is  the  extirpation  of  the  entire  cyst  and  the  remains  of  the  gland.  This 
is  a  much  more  difficult  operation  than  the  others,  and  in  some  in- 
stances may  be  necessary.  When  thoroughly  done  it  proves  suc- 
cessful. 

Fig.  390. 


i 

Full-curved  Needles. 

Efforts  have  been  made  to  destroy  the  cyst  by  injections  of  the 
tincture  of  iodin,  but  this  is  unsafe  practice  on  account  of  the  great 
swelling  likely  to  occur,  and  the  danger  of  causing  suffocation  by 
forcing  the  tongue  into  the  fauces.  The  late  Professor  Garretson  men- 
tions such  a  case  as  occurring  in  his  own  practice  which  nearly  proved 
fatal. 

The  use  of  stimulating  applications  to  the  inner  walls  of  the  cyst 
is  to  be  deprecated  for  the  same  reasons,  and  also  because  they  are 
unnecessary,  as  nature  very  soon  reduces  the  expanded  duct  to  its 
proper  caliber  after  the  establishment  of  patulous  openings  in  the  walls 
of  the  cvst. 


INDEX. 


Abscess,   alveolar,   antral   disease   from, 

causes  of,  72. 

of  jaws  following  fractures,  222. 
Abscesses,  classification  of,  73. 

cold,  322. 

tubercular,  322,  329. 
Acetanilid  as  a  surgical  dressing,  341. 

as  an  antiseptic,  341. 
Acetate    of   aluminum    in    inflammation, 

65. 
Acini,  461. 

Acinous  adenoma,  474. 
Aconite  in  trifacial  neuralgia,  413. 
Actinocladothrix,  344. 
Actinomyces,  32. 

action  of  on  the  tissues.  352. 
Actinomycosis,  32,  344,  574. 

bovis,  344. 

classification  of,  346. 

etiology  of,  347. 

geographical  distribution  of,  349. 

inoculability  of,  346. 

of  the  cheek,  354. 

of  the  jaws,  354. 

of  the  neck,  353. 

pathology  of,  352. 

secondary  infection  of,  351. 

sources  of  infection  of,  349. 

statistics  of,  350. 

treatment  of,  356. 
Acupressure,  170. 
Acute  abscesses,  75. 

tetanus,  132. 
Adeno-carcinoma,  479. 

-myxoma,  479. 
Adenoma  destruens,  471,  478,  479. 

of  mucous  membrane,  477. 

of  palate,  481. 

of  salivary  glands,  483. 

of  skin,  475. 

of  tongue,  481. 
Adenomata,  470. 
Aerobic  microbes,  2. 
Agnew's  operation  for  excision  of  max- 
illary nerve,  418. 
Alimentary  tract  as  an  avenue  of  infec- 
tion. 311. 
Alum  in  ulcers,  87. 


Alveolar  abscess,    septic   infection  from, 

367- 
process,  caries  of,  325. 

fractures  of,  201. 

of  jaw,  excision  of,  590. 
sarcoma,  633. 
Ammonia  in  shock,  143. 
Anaerobic  microbes,  2. 
Ankylosis  of  jaws,  255. 

permanent,  257. 

temporary,  255. 
Anemia,  40. 

Anesthesia,  partial,  dangers  from,  145. 
Anesthetics  for  mouth-surgery,  432. 
Aneurism,  cirsoid,  620. 
Angiomata,  origin  of,  616. 
Angle  apparatus   for  jaw   fracture,  210, 

211,  220. 
Anodynes,  caution  in  use  of,  ^"j. 
Anthrax,  bacillus  of,  31. 
Antipyretics  in  pyemia,  119. 
Antipyrine  in  trifacial  neuralgia,  413. 
Antisepsis,  general  principles  of,  z^. 

in  surgery,  61,  166. 
Antiseptic  mouth-washes,  267. 
solutions,  2>T- 

in  treatment  of  abscess,  76. 
Antiseptics  in  tuberculosis,  341. 
Antitoxic    properties    of    the    medullary 

cells,  136. 
Antitoxin     treatment     of     tetanus     and 

diphtheria,  135. 
a   constituent   of   the   medullary   cells, 

135- 
Antrum,  anatomy  of,  358. 
carcinoma  of,  568. 
chondroma  of,  599. 
cystic  tumors  of,  389. 
diseases  of,  364. 
drainage  of,  380. 
foreign  bodies  in,  370. 
mode  of  access  to,  701. 
mucous  cysts  of,  701. 

engorgements  of.  371. 
necrosis  of  walls  of,  386. 
opening  of,  376. 
polypus  of,  392. 
sarcoma  of,  649. 
suppuration  of,  364,  374. 


46 


705 


7o6 


INDEX. 


Antrum,  syphilitic  ulceration  of,  382. 

traumatisms  of,  371. 

trocar  for,  JHl- 
Aphthous  stomatitis,  285. 
Arsenic  in  trifacial  neuralgia,  412. 

in  tuberculosis,  340. 
Arsenical  necrosis,  275. 
Arsenious  acid,  caution  in  use  of,  275. 
Arterial  hemorrhage,   169. 
Arteries,  ligation  of,  584. 
Artificial  joint,   formation   of,   for  anky- 
losis, 262. 
Asepsis  in  wound-treatment,   168. 

maintenance  of,  yj- 
Aseptic  fever,  102. 
Asthenic  fever,  57. 
Astringents  in  stomatitis,  285. 
Atheromatous  degeneration,  97. 
Auto-infection  of  tuberculosis,  311. 

Bacilli,  6. 

antagonism  of  leucocytes  to,  51. 

Hansen-Neisser,  30. 

spore  formations  in,  12. 
Bacillus  anthracis,  31. 

coli  communis,  21. 

crassus  sputigenus,  34. 

dentalis  viridans,  34. 

mallei,  26. 

of  Asiatic  cholera,  8. 

of  leprosy,  29. 

of  malignant  edema,  28. 

of  syphilis,  30. 

proteus  vulgaris,  14. 

pulpae  pyogenes,  34. 

pyocyaneus,  18. 

pyogenes  fetidus,  19. 

salivarius  septicus,  34. 

tetani,  24,  130. 

tuberculosis,  25,  311. 
Bacteria,  action  of  on  living  tissues,  35. 

functions  of,  5. 

microscopic  study  of,  4. 

of  carcinoma,  531. 

of  the  mouth,  2,  32,  35. 
Bactericidal  property  of  serum,  53. 
Bacterium  gingivae  pyogenes,  34. 

ray,  or  "ray  fungus,"  344. 
Balsam  of  Peru  in  tuberculosis,  341. 
in  leucoplakia,  305. 
in  ulcers,  87. 
Bandages  for  jaw-fracture,  208. 
Barton  bandage  for  jaw-fracture,  209. 
Belladonna  in  trifacial  neuralgia,  413. 
Billroth's     operation     for     excision     of 

tongue,  579. 
Birth-marks,  616. 
Black-heads,    695. 
Blastomyces  of  carcinoma,  531. 
Blood-clots,  removal  of  in  hemorrhage, 

170. 
Blood   serum,    germicidal   properties   of, 

53- 
Bone,  implantation  of  for  ununited  frac- 
ture, 245. 


Bone  cysts,  493. 
-grafting,_245. 
reproduction  of,  280. 
tissue,  death  of,  92. 
tuberculosis  of,  318. 
tumors,  removal  of,  615. 
Boric  acid  as  an  antiseptic,  37. 
in  antral  disease,  379,  386. 
in  inflammation,  65. 
in  stomatitis,  287,  288,  290. 
in  ulcers,  88. 
Broca's     classification     of     odontomata, 

667. 
Bronchitis  putrida,  108. 
Brophy's  operation  for  cleft  palate,  444. 
Bruns's  operation  for  restoration  of  lip, 

562. 
Bullet,  deformation  of,  178. 

effect  of  rotation  of  on  wounds,  177. 
heating  of,  178. 
Buried  suture,  154. 
Button  suture,  154. 
Butyl  chloral  in  neuralgia,  413. 

Calcification  of  tubercular  tissue,  316. 
Calcium,    supply    of    during    pregnancy, 

427. 
Calculi,  salivary,  395. 
Callous  ulcer,  84. 
Callus,    formation   of   in   bone-fractures, 

241. 
Camphor  in  erysipelas,  129. 
Cancellous  osteomata,  611. 
Cancer  aquaticus,  99. 

cell  nests,  517. 

diagnosis  of,  533. 

encephaloid,  520. 

exciting  causes  of,  532. 

hereditary  transmission  of,  530. 

increased  mortality  from,  526. 

mortality,  table  of,  528. 

predisposing  causes  of,  530. 

scirrhus,  520. 

treatment  of,  536,  546. 
Cancerous  cachexia,  535. 
Cancrum  oris,  288. 
Canker  sore-mouth,  285. 
Cannabis    indica    in    trifacial    neuralgia, 

413- 
Capillary  hemorrhage,  169,  170. 
Carbolic  acid  as  an  antiseptic,  "jd. 

in  antral  disease,  379. 

in  erysipelas,  128. 

in  inflammation,  63. 
Carbonate     of     ammonium     in     pyemia. 

Carcinoma,  cylindrical-celled,  518. 
glandular,  519. 
histology  of,  515. 
malignancy  of,  520. 
of  the  antrum,  568. 
of  the  buccal   mucous  membrane.  303, 

564. 
of  the  cheek.  566. 
of  the  face,  543- 


INDEX. 


707 


Carcinoma  of  the  lip,  55;?. 

of  the  salivary  glands,  582. 

of  the  palate  and  uvula,  571. 

of  the  pharynx,  571. 

of  the  skin,  540. 

of  the  tongue,  572. 

of  the  tonsils,  580. 

squamous-celled,  517. 
Caries,  95. 

of  bone,  320. 
Cartilage,     immunity     of     from     cancer, 

542. 

resistance  of  to  sarcoma,  041. 
Caseous  degeneration,  315. 
Catarrh,  antral  disease  from,  371. 
Catarrhal  inflammation,  43. 

stomatitis,  284. 
Catgut  ligatures,  148. 
Caustics,  use  of  in  cancer,  537,  546,  575. 

use  of  in  lupus,  341. 
Cavernous  angioma,  617. 
Cell-multiplication,  process  of,  159. 
Cells,  wandering,  50. 
Cement,   use   of  with   interdental   splint, 

217. 
Cementomes,  671. 
Central  sarcoma,  654. 
Cheek,  carcinoma  of,  566. 

actinomycosis  of,  354. 
Cheever's   operation   for   carcinoma   of 

the  tonsils,  582. 
Chemical  irritants,  39. 
Chiloplasty,  431. 
Chilorrhaphy,  431. 
Chimney-sweep's  cancer,  541. 
Chloral  as  an  anesthetic,  dy. 

hydrate  in  tetanus^  135. 
Chlorate  of  potash  in  stomatitis,  288. 
Chloroform  as  an  anesthetic,  432. 
Cholera,  Asiatic,  bacillus  of,  8. 
Chondroma  of  the  jaws,  599. 

of  salivary  glands,  601. 
Chondromata,  596. 
Chondro-sarcoma,  649. 
Chromic  acid  in  ulcers,  87. 
Chronic  abscess,  78. 

tetanus,  134. 
Cicatricial  ankylosis,  258. 
Cicatrization,  85. 

Cimicifuga  in  trifacial  neuralgia,  413. 
Circumscribed  abscess,  74. 
Cirsoid  aneurism,  620. 
Clamp  suture,  154. 
Cleanliness,  surgical,  166. 
Cleft  palate,  420. 

best  time  for  operation,  432. 
implantation  of  portion  of  the  tongue 

in,  445- 
mechanical  treatment  of,  447. 
surgical   treatment  of,  431. 
Coagulants,  use  of  in  treatment  of  nevi, 

624. 
Coagulation-necrosis,  96. 
Coaptation  of  wounds,  171. 
Cobbler's  suture,  154. 


Cocain  in  trifacial  neuralgia,  413. 

Cocci,  multiplication  of,  li,  12. 

Coccus  salivarius  septicus,  34. 

Coffee  in  shock,  143. 

Cohnheim's     classification     of     tumors, 

456. 
Cold  in  treatment  of  inflammation,  65. 

abscesses,  69. 
pyogenic  cocci  in,  20. 
Collapse,  138. 

Coloring   matter,    absorption   of   in    sar- 
comata, 636. 
Comedo,  695. 

Comminuted  fractures,  20I. 
Complicated  fractures,  201. 
Composite  odontomes,  678. 
Compound  follicular  odontomes,  672. 

fractures,  201. 
Compressed  air  in  gunshot  wounds,  177. 
Condyle,  excision  of,  263. 
Constitutional    treatment    of    inflamma- 
tion, 70. 
Continuous  suture,  151. 
Contour,     restoration     of     in     gunshot 

wounds,  196. 
Contrast  staining,  4. 
Cornu  cutaneum,  467. 
Corroding  ulcer,  84. 
Corrosive  sublimate  as  an  antiseptic,  76. 

in  inflammation,  63. 
Coryza,  acute,  371. 

chronic,  372. 
Counter-irritants   in   inflammation,   70. 
Croton  chloral  in  trifacial  neuralgia,  4i3- 
Cryer's    operation    for    excision    of    in- 
ferior maxillary  nerve,  418. 
Curdy  pus,  56. 
Cutaneous  epithelioma,  546. 

horn,  467. 
Cy!''ndrical-celled  carcinoma,  518. 
Cylindroma  carcinomatodes,  520. 
Cystomata,  485. 
Cysts,  dentigerous,  500,  504. 

dermoid,  502. 

growth  of,  488. 

m.uciparous,  698. 

mucous,  of  the  antrum,  389,  701. 

multilocular,  of  the  jaws,  493. 

of  disintegration,  486. 

of  the  jaws  and  teeth,  489. 

of  the  mucous  membrane,  698. 

of  salivary  glands,  701. 

of  the  skin,  695. 

retention,  694. 

sebaceous,  697. 

sudoriparous,  698. 

Daughter  nuclei,  161. 

Davies-Colley  operation  for  cleft  palate, 

443- 
Deep-seated  abscesses, -73. 
Deformity,     prevention     of    in     gunshot 

wounds,   196. 
Degenerative  inflammation,  43. 
Dental  operations,  shock  from,  143. 


7o8 


INDEX. 


Denticles,    presence    of    in    odontomes, 

673. 
Dentigerous  cysts,  500,  504. 
Depletion,  methods  of,  63. 
Dermoid  cysts,  502. 
Development,  defects  of,  423,  426. 
Diagnosis  of  acute  inflammation,  58. 

of  actinomycosis,  353. 

of  adenoma,  466,  477,  480,  482,  484. 

of  ankylosis,  258. 

of  angiomata,  617. 

of  carcinoma,  533,  545,  557,  573- 

of  chondroma,  597. 

of  cystic  tumor,  490. 

of  dentigerous  cysts,  510. 

of  epithelioma,  548. 

of  erysipelas,  124. 

of  fibroma,  590,  594. 

of    fractures    of   the    inferior   maxilla, 
206. 

of  gunshot  wounds,  174. 

of  leucoplakia,  298. 

of  mucous  cysts  of  the  antrum,  391. 

of  multilocular  cysts,  498. 

of  odontomata,  679,  682. 

of  papilloma,  466. 

of  parotitis,  394. 

of  polypus  of  the  antrum,  392. 

of  pyemia,  1 18. 

of  salivary  calculi,  398. 

of  salivary  fistulse,  399. 

of  sarcoma,  643. 

of  septicemia,  no. 

of  suppuration  of  the  antrum,  375. 

of  tetanus,   134. 

of  trifacial  neuralgia,  409. 

of  tuberculosis  of  bone,  322. 

of  tuberculosis  of  the  skin,  333. 

of  ulceration  of  the  antrum,  384. 
Diapedesis,  50. 
Diet  in  inflammation,  66. 
Differential     diagnosis     of     dentigerous 
cysts,  511. 
of  leucoplakia,  302. 
of  sarcoma,  643. 

of  suppuration  of  the  antrum,  375. 
of  tuberculosis  of  bone,  324. 
of  tuberculosis  of  the  skin,  338. 
of  ulceration  of  the.  antrum,  384. 
Diffuse  abscesses,  ']'^. 
Digitalis  in  pyemia,   119. 

in  shock,  143. 
Dilatation,  hyperemias  of,  42. 
Dimanche,  ]\Iadame,  467. 
Diphtheria,  antitoxin  treatment  of,  136. 
Diplococcus  pneumoniae.  7. 
Disease,  germ  theory  of,  i. 

hereditary  commimication  of.  36,  530. 
Diseases  from  bacteria  of  the  mouth,  34. 
Dislocations,  classification  of,  248. 

treatment  of,  252. 
Drainage  in  antral  disease,  380. 

of  wounds.  171. 

tube  for  antrum,  378. 
ligature,  575. 


Dressings  of  wounds,  172. 
Dropsy  of  the  antrum,  389. 
Dry  gangrene,  98. 

Duct-compressor,  utilization  of  for  jaw- 
fracture,  217. 

Eburnated  osteomata,  603. 

Ecraseur,  use  of  in  excision  of  tongue, 

576. 
Eczema,   differentiation  of  from  cancer, 

557- 
Edema,  malignant,  74. 

bacillus  of,  30. 
Electricity  in  trifacial  neuralgia,  413. 
Embolism,  115. 

Embryo,  germinal  layers  of,  451. 
Emphysematous  gangrene,  99. 
Emprosthotonos,  133. 
Encephaloid   cancer,   520. 
Endosteal  chondroma,  599. 

sarcoma,  654. 
Endostosis,  603. 
Endothelial  cysts,  486. 
Engine,  surgical,  327,  662,  665. 
Enucleation  of  fibromata,  594. 
Epileptiform  neuralgia,  408. 
Epithelial  cysts,  486. 

nests,  541. 

odontomes,  493,  494. 

tumors,  460. 
Epithelioma,  539,  546. 
Epulis,  589,  647. 
Erethistic  ulcer,  83. 
Erysipelas,  120. 

antagonism  of  to  sarcoma,  645. 

contagiousness  of,  122. 

neonatorum,  126. 

of  the  mucous  membrane,  127,  282.  295. 
Esmarch's  operation  for  excision  of  lip, 
560. 
for  excision  of  lower  jaw,  660. 
for  excision  of  tongue,  578. 

rhinoplasty,  550. 
Ether,  administration  of,  434. 
Exanthematous  necrosis,  273. 
Exostosis,  603. 

Explosive  effects  of  projectiles.  175.  176. 
Extravasation,  170. 
Exudation,  43. 

cysts,  486. 

Face,  carcinoma  of,  543. 

gunshot  wounds  of.  184.  188. 

osteo-tuberculosis  of,  324. 
Facial   erysipelas,   125. 

neuralgia,  406. 

surgical  treatment  of,  414. 
therapeutic  treatment  of,  412. 
False  ankylosis,  257.  260. 
Fatty  degeneration  in  sarcoma.  639. 
Fenger's  operation  for  hare-lip.  437- 
Fergusson's    operation    for    cleft    palate, 

441. 
Fever,  asthenic,  57. 

sthenic,  57. 

traumatic  inflammatory.  102. 


INDEX. 


709 


Fibrin-fcnnont,   io_'. 
Fibrinous  innainmalion,  43. 
Fibro-chondromata,  597. 

-sarcoma,  648. 
Fibroma  of  the  gums,  589. 

of  the  jaws,  591. 

of  tlie  skin,  595. 
Fibromata,  586. 
Fibrous  ankylosis,  258. 

odontomes,  670. 
Fillebrown's  operation   for  hare-lip,  437. 
First  intention,  healing  by,  163. 
Fistula,  salivary,  399. 
Flap  operations,  550. 
Follicular  odontomes,  500. 
Forcipressure,  170. 
Fracture  clamp,  214. 

lines  of,  205. 

treatment  of,  208. 
Fractures,  classification  of,  198. 

delayed  union  of,  239. 
Function,  disturbance  of,  45. 
Fungoid  pulps,  590. 
Fungous  ulcer,  83. 

Gangr.ena  oris,  99. 
Gangrene,  95. 

Gangrenous  tooth-pulps,  34. 
Garretson's    operation   for    exsection    of 
lower  jaw,  661. 
for    excision    of    maxillary    nerve, 

Gelsemium  in  trifacial  neuralgia,  412. 
General   inflammation,  44. 

disease  caused  by  mouth  bacteria,  34. 
Gentian  anilin  water,  5. 
Germ  theory  of  disease,  i. 
Giant-celled  sarcoma,  632. 
Giant  cells,  structure  of,  315. 
Glanders,  bacillus  of,  26. 
Glands,  chondroma  of,  601. 

enlargement  of  in  cancer,  555,  569. 
Glandular  carcinoma,  519. 

hyperplasias,  478. 

infection  in  carcinoma,  545. 
Glossitis,  superficial,  294. 
Glover's  suture,  151. 

Golding-Bird  operation  for  hare-lip,  441. 
Gonococcus,  2^. 
Goodwillie's   appliance  for   ankylosis   of 

the  jaw,  262. 
Gram's  staining  method,  5. 
Granulation,  healing  by,  164. 
Granulation-tissue,  165. 
Granulomata,  69. 

Grippe,  la,  antral  disease  from,  372. 
Grntuni,  696. 

Gummata  of  the  tongue,  574. 
Gummy  pus,  57. 
Gums,  fibroma  of,  589. 
Gunshot  wounds,  173. 

explosive  effects  of,  176. 

of  the  face,  184. 

statistics  of.  174,   181,  185,   187. 

symptoms  of,  194. 


H.vMii.TON  bandage  for  jaw-fracture,  209. 
Hammond  wire  splint  for  jaw-fracture, 

213. 
Hansen-Neisser  bacillus,  30. 
Hard  fibroma,  577. 
Hare-lip,  423. 

best  time  fior  operation,  439. 

operations  for,  437. 
Heat  in  treatment  of  inflammation,  65. 
Heath's  bandage  for  jaw-fracture,  208. 
Hemorrhage,  arrest  of  by  ligatures,  149. 

arrest  of  in  wound-treatment,  169. 

control     of     in     operations     on     the 
tongue,  575. 

statistics  of  death  from  in  battle,  180. 
Hemorrhagic  ulcer,  84. 
Hereditary  transmission  of  cancer,  530. 

of  tuberculosis,  309. 
Heredity  as  a  factor  in  cleft  palate,  428. 

influence    of   on   the   jaws   and   teeth, 
689. 
Hernia  of  the  fang,  676. 
Herpes  zoster,  294. 
Horn,  cicatricial,  of  hand,  468. 

cutaneous,  467. 
Horse-hair  ligatures,  148. 
Hospital  gangrene,  100. 
Hueter's  operation  for  restoration  of  lip, 

562. 
Human    organism,    susceptibility    of    to 

bacterial  infection,  15. 
Hunter's  law  of  inflammation,  45. 
Hydrogen  peroxid  in  antral  disease,  379. 
Hydraulic  pressure  in  gunshot  wounds, 

176. 
Hydrops  antri,  389. 
Hyperemia,  40. 

of  dilatation,  42. 

of  irritation,  42. 

of  paralysis,  42. 
Hyperostosis,  603. 

Ice-bag,  use  of  in  inflammation,  65. 
Ichorous  pus,  56. 
Ichthyol  in  erysipelas,  128. 

in  ulcers,  88. 
Ichthyosis  lingua,  294. 
Idiopathic  erysipelas,   123. 

tetanus,  131. 
Incubation,  period  of  in  tetanus,  131. 
Indurative  inflammation,  43. 
Infantile  tetanus,  132. 
Infarction,  115. 

Infection,  avenues  of,  34,  108,  309. 
Infective  inflammation,  44. 
Inflamed  ulcer,  83. 
Inflammation,  acute,  symptoms  of,  45,  58. 

chronic,  68. 

germicides  in,  63. 

phenomena  of,  38. 

predisposing  causes  of,  57. 

suppurative,  of  antrum,' 364. 

treatment  of,  61. 
Inflammatory    exudates,  dangers  from, 
60. 


47 


INDEX. 


710 

Infundibulum,    communication   of  with 

antrum,  362. 
Instruments,  sterilization  of,  311. 
Interdental  splint  bridge,  196. 

splints,  214,  216,  217,  219,  230. 
Internal  hemorrhage,  169. 
Interrupted  suture,  152. 
lodin  in  inflammation,  63. 

in  ulcers,  87. 

staining  solution,  5. 
Iodoform,  substitute  for,  zi- 
Iron  in  trifacial  neuralgia,  412. 
Irritants,  chemical,  39. 

mechanical,  39. 

nervous,  39. 

septic,  39. 
Ischemia,  40. 
Ivory,  abscesses  in,  74. 
Ivory  exostoses,  603. 

Jaw,  gunshot  wounds  of,  189. 
Jaws,    abscess    of    following    fractures, 
222. 

actinomycosis  of,  354. 

ankylosis  of,  255. 

cancer  of,  567. 

chondroma  of,  599. 

cysts  of,  489,  493. 

dislocation  of,  248. 

displacements  of,  204. 

fibroma  of,  591. 

fractures  of,  198,  208,  224. 

hypertrophy  of,  606. 

necrosis  of,  268,  273. 

operations  on,  211. 

periostitis  of,  264. 

restoration  of  in  gunshot  wounds,  196. 

sarcoma  of,  646,  652,  659. 

subluxation  of,  254. 

upper,  resection  of,  661,  663. 

.  Kangaroo  ligatures,  148. 
ICaryokinesis,  159,  453. 
Keloid,  587. 
Keratosis,  544. 
Kingsley's    splint,    author's    modification 

of,  216. 
Koch's  tuberculin  in  actinomycosis,  356. 
Kocher's     operation     for     excision     of 

tongue,  580. 
Konig's  rhinoplasty,  551. 

Langenbeck's  operation  for  carcinoma 
of  the  tonsils,  581. 
for  cleft  palate,  441. 
for  excision  of  tongue,  579. 
for  restoration  of  lip,  561. 
rhinoplasty,  550. 
Laudable  pus,  56. 
Leeches  in  inflammation,  64. 
Leontiasis  ossea,  605.  '       ^ 

Lepra  cells,  29. 
Leprosy,  bacillus  of,  29. 
Leptothrix  buccalis,  8,  10. 
gigantise,  10. 


Leucocytes,  function  of,  50. 

migration  of,  46,  50. 
Leucoma,  294,  565. 
Leucomaines,  35. 
Leucoplakia,  294,  565. 
Ligatures,  148. 

for  constriction  of  tongue,  575. 

materials  for,  148. 
Lip,  carcinoma  of,  553. 

congenital  fissures  of,  420. 
Lips,  cysts  of,  699. 
Listerine  in  stomatitis,  291. 
Lock-jaw,  132. 
Lotion  for  comedones,  696. 
Lumpy- jaw,  32. 
Lupus  exedens,  335. 

exfoliativus,  334. 

exulcerans,  334. 

hypertrophicus,  335. 

maculosus,  334. 

serpiginosus,  335. 

vorax,  335. 

vulgaris,  331. 
Lympho-sarcoma,  627. 

Malar,  gunshot  wounds  of,  189. 
Malignant  edema,  74. 
growths,  differential  diagnosis  of,  643. 
ulcers,  84. 
Malposed  teeth,  367. 
Marshall's     modification     of    Kingsley's 

splint,  216. 
Massage  in  treatment  of  fractures,  246. 
Maternal  impressions.  429. 
Maxilla,  inferior,  dislocation  of,  248. 
fractures  of,  198,  201,  208. 
superior,  fractures  of,  224. 
Maxillse,  chondroma  of,  599. 
Maxillary  sinus,  anatomy  of,  358. 

diseases  of,  364. 
Mechanical  irritants,  39. 
Meckel's  ganglion,  removal  of  for  neu- 
ralgia, 416. 
Medullary  cells,   antitoxic  properties  of, 

136. 
Melanin,  636. 
Melano-sarcoma,  635. 
Mental  emotion,  shock  from,  146. 
Menthol  in  trifacial  neuralgia,  413. 
Mercurial  necrosis,  274. 

periostitis,  266. 
Mercuric  chlorid  as  an  antiseptic,  76. 

for  actinomycosis,  356. 
Mercury,  effects  of  on  the  general   sys- 
tem, 266. 
bichlorid  as  an  antiseptic,  "jd. 

in  antral  disease,  379. 
in  syphilis,  279. 
Metastatic  abscesses,  116. 
Microbes,  aerobic,  2. 

pyogenic,  13.  32,  54. 
Micrococci,  6. 

Micrococcus  gingivae  pyogenes,  34. 
pyogenes  tenuis,  17. 
tetragenus,  19,  34. 


INDEX. 


711 


Micro-organisms,  staining  of,  4. 
Miciilicz's   operation   for   carcinoma   of 

the  tonsils,  582. 
Migraine,  403. 
Miliary  carcinosis,  524. 
Milium,  6g6. 

Mixed-cell  sarcoma,  637. 
Moist  gangrene,  99. 
Moles,  595. 
Morphia  in  tetanus,  135. 

in  trifacial  neuralgia,  413. 
Motion   as   a   cause   of   delayed    union, 

24T. 
Mouth,  bacteria  of,  2,  32,  35,  168. 

diseases  caused  by,  34. 
cancer  of,  564. 

inflammatory  affections  of,  282. 
washes,  antiseptic,  267. 
Muciparous  cysts,  698. 
Muco-periosteal  sarcoma,  649. 
Muco-pus,  57. 

Mucous  cysts  of  the  antrum,  389,  701. 
glands,  cystic  degeneration  of,  479. 
membrane,  adenoma  of,  478. 

buccal,  cancer  of,  564. 

cysts  of,  698. 

erysipelas  of,  127.  282,  295. 

inflammatory  affections  of,  282. 

tuberculosis  of,  335. 
Multilocular  cystic  epithelial  tumor,  494. 

cysts  of  the  jaws,  493. 
Multiple  fractures,  201. 
Mummification,  98. 
Mumps,  394. 
Mycosis,  III. 
Myeloid  sarcoma,  632. 

Nail  horns,  469. 

Nasal  passages,  occlusion  of  by  fibroma, 

592. 
Nasal  septum,  sarcoma  of,  653. 
Neck,  actinomycosis  of,  353. 
Necrosis,  91. 

arsenical,  275. 

exanthematous,  273. 

mercurial,  274. 

of  the  jaws,  268,  273. 

of  walls  of  antrum,  386. 

phosphorus,  2^6. 

syphilitic,  277. 
Needles,  surgical,  150. 
Nekton's     operation     for     hare-lip,     au- 
thor's modification  of,  445. 
Nerve-stretching  for  neuralgia,  414. 
Nerves,  excision  of  for  neuralgia,  414. 
Nervous  irritants,  39. 
Neuralgia,  etiology  of,  401. 

trifacial,  406,  412. 

treatment  of,  412. 
Neuritis,  neuralgia  from,  409. 
Nevus,  cavernous,  617. 

simple,  616,  623. 
Nitrate  of  silver  in  inflammation,  63. 

in  ulcers.  87. 
Nitro-glycerin  in  shock,  143. 


Noma,  99. 

bacillus  of,  29. 
Nun-pathogenic  bacteria,  5. 
Nose,  osteo-tuberculosis  of,  325. 

gunshot  wounds  of,  188. 

plastic  operations  on,  550. 

syphilitic  ulceration  of,  383. 
Nursing  bottles,  promiscuous  use  of,  287. 
Nutrition,  fault}',  as  a  cause  of  cleft  pal- 
ate, 426. 

Oat-seed-like     spindle-celled     sarcoma, 

631. 
Odonto-sarcoma,  655. 
Odontomata,  classification  of,  667. 

spontaneous  expulsion  of,  684. 
Odontomes,  composite,  678. 

compound  follicular,  672. 

coronaires,  669. 

embryoplastiques,  667. 

fibrous,  669. 

follicular,  500. 

odontoplastiques,  668. 

radicular,  676. 
Oidium  lactis,  9. 
Oil  of  peppermint  in  trifacial  neuralgia, 

413. 
Ointment  for  comedones.  696. 
Ointments  for  erysipelas,  128. 
Operations : 
actinomycosis,  356. 
adenoma,  480,  483,  484. 
ankylosis  of  the  jaws,  260. 
carcinoma  of  the  face,  549. 

of  the  lip,  559. 

of  the  mouth,  569. 
cystic  tumors  of  the  antrum,  391. 
dentigerous  cysts,  505,  512. 
dermoid  cysts,  505. 
enucleation  of  fibroma,  594. 
excision  of  tongue,  576. 
hare-lip  and  cleft  palate,  432. 
leucoplakia,  306. 

multilocular   cysts   of  the  jaws,  498. 
myeloid   sarcoma  of  superior  maxilla, 

632.  _ 
necrosis  of  the  antrum,  386. 
papillomatous  tumors,  467. 
polypus  of  the  antrum,  393. 
removal    of    foreign    bodies    from    the 

antrum,  370. 
removal  of  salivary  calculi,  398. 
staphylorrhaphy,  445. 
suppuration  of  the  antrum,  2!/^- 
trifacial  neuralgia.  414. 
tuberculosis  of  bones  of  the  face,  326. 
uranorrhaphy,  441. 
Operative  treatment  of  nevi,  623. 

of  ankylosis,  262. 

of  actinomycosis.  356. 

of  carcinoma,  548,  549,  559,  569,  572, 
575,  581,  583. 

of  chondroma,  601. 

of  cleft  palate,  431. 

of  epithelioma,  548. 


12 


INDEX. 


Operative  treatment  of  tibroma,  594. 
of  neuralgia,  414. 
of  odontoma,  686. 
of  sarcoma,  644,  659. 
of  ulcers,  88. 
Opisthotonos,  133. 
Opium  in  shock,  143. 

in  trifacial  neuralgia,  413. 
Osseous  ankylosis,  258. 
Osteo-chondroma  of  jaws,  600. 
-sarcoma,  649. 

-tuberculosis  of  the  face,  324. 
Osteoma  durum,  605. 
Osteomata,  cancellous,  611. 
compact,  603. 

sarcomatous  transformation  of,  615. 
Osteophytes,  603. 
Owen's  operation  for  cleft  palate,  440. 

Pachyakria,  607. 
Palatal  defects,  420. 

processes,  non-union  of,  426. 
Palate,  adenoma  of,  480. 
bony,  tuberculosis  of,  325. 
carcinoma  of,  571. 
soft,  cysts  of,  699. 
Pancoast's     operation     for     excision     of 

maxillary  nerve,  418. 
Papillomata,  462. 

hard,  of  the  skin,  464. 
Paralysis,  hyperemia  of,  42. 
Parasites,  i. 

Parenchymatous  inflammation,  43. 
Parotid  adenoma,  484. 
gland,  carcinoma  of,  582. 
chondroma  of,  601. 
cysts  of,  701. 
inflammation  of,  394. 
osteoma  of,  613. 
sarcoma  of,  656. 
Parotitis,  394. 
Paste  for  leucoplakia,  305. 
Pathogenic  bacteria,  5,  32. 

destroyed  by  leucocytes,  51. 
Patient,  position  of  in  mouth-operations, 

435- . 
Perforating  ulcer,  84. 
Periosteal  chondroma,  599. 

cysts,  490. 

osteoma,  604. 

sarcoma,  646. 
Periostitis,  acute  diffuse,  265. 

chronic,  267. 

mercurial,  266. 
,  of  the  jaws,  264. 
Permanganate   of   potash   in   inflamma- 
tion, 62). 
in  ulcers,  87. 
Phagedenic  ulcer,  84. 
Phagocytes,  function  of,  50. 
Phagocytosis,  50. 
Pharynx,  tuberculosis  of,  336. 

carcinoma  of,  571. 
Phenacetin  as  an  anesthetic,  6"]. 

in  trifacial  neuralgia,  413. 


Phlegmonous  abscesses,  73. 

cellulitis,  125. 

erysipelas,  125. 

inflammation,  43. 
Phosphorus  in  trifacial  neuralgia,  413. 

necrosis,  276. 
Pigment  epulis,  648. 
Pin  suture,  152. 

Pipe-smoking,  cancer  caused  by,  556. 
Plaques  opalines,  294. 
Plastic  operations  for  ankylosis,  260. 

for  cancer,  550. 
Plethora,  40. 
Pleurothotonos,  133. 
Plexiform  angioma,  620. 
Pneumococcus,  34. 
Points  douloureux,  409. 
Polypi,  nasal,  removal  of,  480. 
Polypus  of  the  antrum,  392. 
Port-wine  stain,  617,  623. 
Potassium   bicarbonate    in   leucoplakia, 
306. 

bromid  in  tetanus,  135. 

chlorate  as  a  mouth-wash,  267. 

iodid  in  actinomycosis,  356. 
in  leucoplakia,  305. 
in  periostitis,  267. 
in  syphilis,  279,  386. 
in  trifacial  neuralgia,  413. 
Poultices  in  inflammation,  65. 
Powders,  use  of  in  antral  disease,  380. 
Pre-natal  infection,  36. 
Pressure  atrophy,  593. 
Primary  adhesion  of  wounds,  163. 

hemorrhage,  169. 
Projectiles,  comparative  effects  of.  175. 
Prognosis  of  adenoma,  474,  477,  480,  483. 

of  actinomycosis,  355. 

of  carcinoma,   536,   546,   558,   571,   574, 
581. 

of  chondroma,  598. 

of  cystic  tumor,  492. 

of  dentigerous  cysts,  512. 

of  erysipelas,  124. 

of  fibroma,  590,  594. 

of  fissures  of  the  palate,  429. 

of   fractures    of  the    inferior   maxilla, 
207. 

of  gangrene,  99. 

of  inflammation,  59. 

of  leucoplakia,  303. 

of  mucous  cysts  of  the  antrum,  391. 

of  multilocular  cysts,  498. 

of  parotitis,  395. 

of  polypus  of  the  antrum,  392. 

of  pyemia,  118. 

of  sarcoma,  644. 

of  septicemia,  iii. 

of  shock,  140. 

of  suppuration  of  the  antrum,  yi^- 

of  tetanus,  134. 

of  tuberculosis  of  bone,  324. 

of  tuberculosis  of  the  skin,  339. 

of  ulceration,  85. 
Projectile  air  in  gunshot  wounds,  177 


INDEX. 


713 


Projectiles,  character  of  wounds  by,  174, 
179- 

pcHetrating  force  of,  174. 
Prophylactic  treatment  of  inflammation, 

61. 
Proud  flesli,  83. 
Pseudo-edema  bacillus,  29. 
Psoriasis  linguae,  294,  296. 
Ptomaines,  35. 

Puerperal  fever,  relationship  to  erysipe- 
las, 121. 
Pulmonary  tissues  as  an  avenue  of  infec- 
tion, 310. 
Pulps,    devitalized,   antral    disease   from, 
366. 

gangrenous  pyemia  from,  34. 

fungoid,  590. 
Pulse,  indications  of,  44. 
Pus,  mechanical  production  of,  20. 

microbes,  13,  32,  54. 

varieties  of,  56. 
Pj'emia,  113. 

from  gangrenous  tooth-pulps,  34. 
Pyocyanine.  18. 

Pyogenic  cocci,  infection  by,  13. 
Pyrogallic  acid  for  epithelioma,  548. 
Pyrozone  in  antral  disease,  379. 

Quilled  suture,  153. 
Quinin  in  erysipelas,  128. 

in  inflammation,  66. 

in  pyemia,  119. 

in  trifacial  neuralgia,  412. 

Rachitis  as  an  exciting  cause  of  chon- 

dromata,  596. 
Racial  types  of  alveolar  arch,  688,  690. 
Radicular  odontomes,  676. 
Ramus,  resection  of  for  sarcoma,  661. 
Ranula,  701. 
Ray  bacterium.  344. 

fungus,  32,  344,  348. 
Repair,  process  of  in  fractures,  241. 
Rest,  physiological,  64,  171. 
Retention  cysts,  694. 
Retropharyngeal  abscesses,  73. 
Rhinoplasty,  illustrations  of,  550,  551. 
Rickets,  relation  of  to  odontomata,  670. 
Risus  sardonicus,   133. 
Rodent  ulcer,  544. 
Rodents,  odontomata  in,  678. 
Roentgen  ray  in  tuberculosis,  341. 
Rotation  of  bullet,  effect  of  on  v^^ounds, 

177- 
Rotter's  operation   for  cleft  palate,  442, 

443. 
Round-celled  sarcoma,  626. 

St.  Anthony's  fire,  120. 
Saline  solution  for  injection,  142. 
Saliva,    pathogenic    micro-organisms   in, 
34-. 

germicidal  properties  of,  169. 
Salivary  calculi,  395. 

fistulas,  399. 


Salivary  glands,  adenoma  of,  483. 
carcinoma  of,  569,  582. 
chondroma  of,  601. 
cysts  of,  701. 
sarcoma  of,  656. 
Salivation,  mercurial,  266,  274. 
Salol  in  trifacial  neuralgia,  413. 
Sapremia,  108. 
Saprophytes,  6. 
Sarcoma,  alveolar,  634. 
endosteal,  654. 
melano-,  635. 
mixed-cell,  637. 
muco-periosteal,  649. 
myeloid,  632. 
odonto-,  655. 

of  the  salivary  glands,  656. 
of  the  skin,  656. 
periosteal,  646. 
round-celled,  626. 
spindle-celled,  628. 
Sarcomata,  classification  of,  625. 
infection  and  dissemination  of,  640. 
origin  of,  625. 
predisposition  to,  643. 
retrogressive  changes  of,  638. 
Scirrhus  cancer,  520. 

tongue,  344- 
Screw-gag  for  opening  the  jaws,  256. 
Scrofula,    identity   of   with   tuberculosis, 

308. 
Scrofulous  inflammation,  43. 
Sebaceous  adenomata,  477. 

cysts,  697. 
Sebum,  695. 

Second  intention,  healing  by.  164. 
Secondary  fever,  104. 

hemorrhage,  169. 
Senn's  classification  of  tumors,  458. 
operation  for  carcinoma  of  the  tonsils, 
582. 
Septic  fever,  103,  113. 
infection,  35. 
irritants,  39. 
Septicemia,  34,  106. 
Sero-pus,  57. 

Serum,  bactericidal  properties  of,  53. 
Sesquioxid  of  iron  in  necrosis,  276. 
Shock,  138. 
death  from.  146. 
from  dental  operations,  143. 
Shotted  suture,  155. 
Shotwell  fracture  clamp,  214. 
Silkworm-gut  ligatures,  148. 
Silver  wire  ligatures,  148. 
Simple  fractures,  198.  209. 
Skin,  adenoma  of,  .475. 
as  an  avenue  of  infection,  312. 
carcinoma  of,  540. 
cysts  of,  695. 
epithelioma  of,  546. 
fibroma  of,  595. 
-grafting.  260. 
sarcoma  of,  656. 
tuberculosis  of,  331. 


■14 


INDEX. 


Skin  warts,  464. 

Skull-cap  for  dislocation  of  jaw,  254. 

Smoker's  patch,  294. 

Soda  sulfite  in  stomatitis,  288. 

Soft  fibroma,  588. 

Somatic  death,  49. 

Spasmotoxin,  25. 

Spermatozoa,  infection  of,  36. 

Spindle-celled  sarcoma,  628. 

Spirilli  cilia,  12. 

Splints,  interdental.  Angle's,  219. 

Hammond's  wire,  214. 

Kingsley's.  217. 

Marshall's  modification  of,  216. 
Sponge-grafting,  88. 
Squamous-celled  carcinoma,  517,  540. 
Staining  solutions,  4,  5. 
Staphylococcus   cereus   albus   et   flavus. 

17. 

pyogenes  aureus,  16,  34. 
albus,  17,  34. 
citreus,  17. 

salivarius  pyogenes,  34. 

viridis  flavescens,  17. 
Staphyloplasty,  431,  445. 
Staphylorrhaphy,  431,  445. 

instruments  for,  436. 
Stasis,  49. 
Sthenic  fever,  57. 
Stimulants,  formulae  for,  147. 
Stomatitis,  282. 

aphthosa,  285. 

catarrhalis,  284. 

parasitica,  287. 

simplex,  283. 

ulcerosa,  288. 
nocens.  290. 
Streptococcus  erysipelatus,  22. 

pyogenes,  11,  18,  34. 

septo-pysemicus,  34. 
Streptothrix  actinomycotica,  344,  347. 
Strychnia  in  shock,  143. 
Subcutaneous  wounds,  158. 
Sudorip'arous  cysts,  698. 
Sulfate  of  copper  in  stomatitis,  290. 
Superficial  abscesses,  73. 

glossitis,  294. 
Suppuration,  phenomena  of,  54. 
Suppurative  fever.  104. 
Surgery,  antiseptic  methods  in.  61. 
Surgical  cleanliness.  166. 

engine,  advantages  of  in  bone  surgery, 
32J.  662,  665. 

tuberculosis,  308.  318. 
Sutton's  classification  of  tumors,  457. 
Sutures,  forms  of,  150. 

of  approximation,  154, 

of  coaptation,  154. 

of  relaxation,  154. 

wire,  for  jaw-fracture,  212. 
Sweat-glands,  adenoma  of,  475. 

cysts  of,  698. 
Syphilis,  bacillus  of,  30. 

differentiation  of  from  cancer,  558. 

manifestations  of  in  the  jaws,  277. 


Syphilis,  systemic  treatment  of,  386. 
Syphilitic  necrosis,  277. 

ulceration  of  antrum,  382. 

mucous  patch,  294. 

Tannic  acid,  injection  of  for  nevi,  624, 
Teeth,  aberration  in  position  of,  688. 

abnormal  development  of,  674. 

antral  disease  from,  367. 

carious,  cancer  caused  by,  566. 

cysts  of,  489. 

irregularities  of,  688. 

malposed,  367. 

supernumerary,    in    dentigerous    cysts, 
494,  508. 

tumors  of,  667. 

warty,  678. 
Temperature,  indications  of,  44. 

reduction  of  in  inflammation,  65. 
Tetanin,  25. 
Tetanotoxin,  25. 
Tetanus,  130. 

acute,  132. 

antitoxin  treatment  of,  135. 

bacillus,  7,  24. 

chronic,  134. 
Thiersch's  solution,  37. 
Third  intention,  healing  by,  166. 
Thomas's  method  of  wiring  jaw-fracture, 

212. 
Thrombo-arteritis,  115. 
Thrombosis,  115. 
Thrush,  287. 

Thyroid  gland,  extract  of,  in  the  treat- 
ment of  fractures,  246. 
Tic  douloureux,  408. 

Tinct.  ferri  perchlor.  for  leucoplakia,  305. 
Tissues,  death  of,  91,  96,  98. 
Tobacco,  carcinoma  caused  by,  556,  565. 

leucoplakia  caused  by,  297. 
Tongue,  adenoma  of,  481. 

carcinoma  of,  572. 

cavernous  angioma  of,  620. 

C3'Sts  of,  700. 

excision  of,  576. 

papilloma  of,  466. 

scirrhus,  344. 

tuberculosis  of,  336. 
Tooth-extraction,  shock  from,  145,  146. 
Tonsils,  carcinoma  of,  580. 
Torpid  ulcers,  84. 
Torsion,  170. 
Toxic  infection,  35, 
Toxines.  35. 
Traumatic  fever,  102. 
Trismus,  132. 
Tubercle,  313. 
Tubercular  abscesses,  329. 
Tuberculosis,  bacillus  of.  25. 

dangers  of  infection  from.  309, 

hereditary  transmission  of,  309. 

of  bone,  318.  325. 

of  mucous  membrane,  331,  335. 

of  skin,  331. 

of  tongue  and  pharj-nx,  336. 


INDEX. 


715 


Tuberculosis,  surgical,  308,  318. 
Tubular  adenoma,  474. 
Tumors,  character  of,  454. 

classification  of,  455,  456,  457. 

cystic,  of  antrum,  389. 

epithelial,  460. 

fibrous,  of  the  skin,  595. 

growth  of,  453. 

origin  of,  450. 

structure  of,  452. 

tooth,  667. 

Ulceration,  80. 
Ulcerative  stomatitis,  288. 
Ulcers,  classification  of,  82. 

microscopic  appearance  of,  81. 

treatment  of,  86. 
Ulna,  fracture  of,  199. 
Unna's  paste  for  comedones,  696. 
Ununited  fractures,  242. 

thyroid  medication  in,  246. 
Uranoplasty,  431,  441. 
Uranorrhaphy.  431,  441. 
Uvula,  carcinoma  of,  571. 

Valerianate  of  zinc  in  trifacial  neural- 
gia, 413- 
Vascular    tissues,    inflammatory    process 

in,  45.  ... 

Vaso-motor    system,    physiologic    action 

of,  42,  _ 
Vela,  artificial,  447. 


Venous  hemorrhage,  169. 

Verruca,  463. 

Vessels,  ligation  of,  149. 

Virchow's  classification  of  tumors,  455. 

Vital  resistance,  50. 

Warts,  463. 
Warty  teeth,  678. 

variety  of  cancer,  555. 
Wedges,  use  of  in  luxation  of  jaw,  253. 
Wens,  697. 
White  mouth,  287. 
Wire  splint  for  jaw  fracture,  213. 

sutures  for  jaw  fracture,  212. 
Wool-sorters'  disease,  31. 
"Worms"  of  the  skin,  695. 
Wounds,    antiseptic    treatment    of,    118, 
168. 

classification  of,  157. 

gunshot,  173. 

of  the  face,  184,  188. 
Wounds,  hea'litig  of,  158. 

treatment  of,  168. 

Yeast  fungi,  3. 

Ziehl's  staining  solution,  4. 
Zinc  chlorid  for  epithelioma,  548. 

injection  of  in  ununited  fracture,  246. 

ointment  in  erysipelas,  128. 
Zona,  294. 

of  the  mucous  membrane,  296. 


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